meta
dict | text
stringlengths 0
55.8k
|
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4400
} | Medical Text: Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-16**]
Date of Birth: [**2083-1-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 54y/o woman with a PMH of H. pylori and
depression admitted with DOE and anemia with HCT of 19. The
patient noted onset of DOE 2 days prior to presentation, with
worsening so that she was unable to ambulate without significant
difficultly over the past 24 hours. She noted black stools 24
hours prior to presentation. Denies previous recent history of
bleeding. She underwent a routine screening colonoscopy in [**2134**]
which demonstrated grade 1 internal hemorrhoids. She denies any
other bleeding (urine, gums). She denies weight changes, fevers,
chills, night sweats. She has nto had any bowel movements since
admission.
In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2
100% RA. On exam she was found to have dark, guaiac + stools. NG
lavage negative. 2 18 guage PIV were placed. She was transfused
1U PRBC.
On arrival to the MICU, the patient is resting comfortably, in
NAD. Denies current CP/SOB. The GI performed an upper endoscopy
on arrival to the MICU which demonstrated a large polyp with no
evidence of current bleeding. Intervention was deferred
overnight for planned excision and biopsy with EUS. She was
transfused 3 units PRBC's with appropriate improvement in her
hct and has been hemodynamically stable in the ICU.
10 point review of systems otherwise negative except as noted
above.
Past Medical History:
Melanoma in-situ, lentigo maligna type - L cheeck [**2133**]
Depression
H. Pylori
Social History:
The patient is married and has one teenage son. She runs the
Gift Shop at [**Hospital1 18**]. The patient denies tobacco, EtOH, IVDU.
Denies over the counter herbal supplements.
Family History:
Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19839**] deficiency
Physical Exam:
VS: T 97.3 HR 59 BP 102/69 RR 18 Sat 99% RA
Gen: wll appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates,
conjunctiva pink
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis
bilaterally, babinski down-going bilaterally
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
[**2137-8-12**] 05:57PM COMMENTS-GREEN TOP
[**2137-8-12**] 05:57PM HGB-7.8* calcHCT-23
[**2137-8-12**] 05:50PM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2137-8-12**] 05:50PM WBC-5.5 RBC-2.22* HGB-6.8* HCT-20.4* MCV-92
MCH-30.8 MCHC-33.4 RDW-14.0
[**2137-8-12**] 05:50PM NEUTS-68.4 LYMPHS-24.4 MONOS-5.5 EOS-1.4
BASOS-0.2
[**2137-8-12**] 05:50PM PLT COUNT-211
[**2137-8-12**] 05:50PM PT-11.3 PTT-21.8* INR(PT)-0.9
[**2137-8-12**] 01:46PM GLUCOSE-95
[**2137-8-12**] 01:46PM UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.4
CHLORIDE-109* TOTAL CO2-29 ANION GAP-7*
[**2137-8-12**] 01:46PM estGFR-Using this
[**2137-8-12**] 01:46PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-57 TOT
BILI-0.2
[**2137-8-12**] 01:46PM WBC-3.9* RBC-2.13*# HGB-6.4*# HCT-18.9*#
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.1
[**2137-8-12**] 01:46PM NEUTS-64.6 LYMPHS-24.2 MONOS-8.8 EOS-1.9
BASOS-0.5
[**2137-8-12**] 01:46PM PLT COUNT-177
[**2137-8-12**] 01:46PM PT-11.9 PTT-23.5 INR(PT)-1.0
[**2137-8-12**] 01:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-8-12**] 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
EGD [**2137-8-12**]: Impression: Polyp in the second part of the
duodenum on wall opposite ampulla Otherwise normal EGD to third
part of the duodenum
Recommendations: Patient will require polypectomy of this polyp.
We do not have the equipment to perform this as an emergency
procedure. Can have clear liquids. give Protonix 40 mg twice
daily.
Colonoscopy [**2137-8-12**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
This is a 54y/o woman with a h/o H. pylori and depression with
acute blood loss anemia, GIB, duodenal polyp.
1. Acute blood loss anemia due to GI bleeding: She presented
with blood loss anemia, secondary to slow GI bleed. She had an
emergent EGD which showed a duodenal polyp. She improved with
transfusion of 3 units of blood with stable hematocrit. She
will need to restart an [**Month/Day/Year **] supplement on discharge.
.
2. Duodenal polyp: Underwent EUS on [**8-15**] for evaluation of polyp
found on initial EGD. EUS showed 3 cm pedunculated polyp in the
second part of the duodenum. The ampulla was identified and was
separate from the mass. The ampulla appeared normal.
On EUS, this lesion appeared as a pedunculated polyp. No
extension of the lesion beyond the submucosa was noted. The
muscularis was clearly identified and was intact. She went for
removal on [**2137-8-16**]. During that EGD, EGD on she was found to
have angioectasia in the stomach (treated with thermal therapy),
a polyp in the second part of the duodenum (treated with
polypectomy, endoclip, and otherwise normal EGD to third part of
the duodenum. She was discharged home after the polypectomy,
with advise to return in the event of pain, hematemesis, or
worsening melena. She will have a CBC approximately 5 days post
discharge, results to her PCP.
.
3. Depression: continuee wellbutrin and celexa.
.
OUTSTANDING TESTS:
Polyp, pathology pending
Medications on Admission:
On Admission:
Bupropion HCl 200 mg Tablet SR daily
Citalopram 20 mg Tablet daily
Lorazepam 0.5 mg Tablet one half to one Tablet(s) by mouth @ hs
no more than 3 nights per week
Ferrous Sulfate 325 mg (65 mg [**Date Range **]) Tablet [**Hospital1 **]
Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC)
On transfer:
BuPROPion (Sustained Release) 200 mg PO QAM
Citalopram Hydrobromide 20 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. [**Hospital1 **] (Ferrous Sulfate) 325 mg (65 mg [**Hospital1 **]) Tablet Sig: One
(1) Tablet PO once a day.
4. Outpatient Lab Work
CBC, [**2137-8-21**]. Results to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] phone
[**Telephone/Fax (1) 250**].
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Acute blood loss anemia
Duodenal polyp
Depression
Discharge Condition:
Stable, hematocrit 31.5, no active bleeding, ambulating without
shortness of breath
Discharge Instructions:
You were admitted with anemia, due to blood loss. The most
likely cause was the polyp in your duodenum, which was slowly
oozing. You improved with transfusions with a stable blood
count throughout your stay after the transfusion. You had the
polyp removed on the day before discharge.
.
No aspirin, or NSAIDs. You do not need to take protonix.
.
Return to the ED if you get short of breath or dizzy. Your
stool will probably turn black from the [**Last Name (LF) **], [**First Name3 (LF) **] that is
expected.
.
Start eating solid food tonight. Stay well hydrated in the next
few days.
Followup Instructions:
Call the GI department to make an appointment with [**Doctor First Name 4370**] [**Doctor Last Name **] in
the next 2-3 weeks. The phone number is [**Telephone/Fax (1) 9557**]. They
will give you the results of your polyp removal.
.
Provider: [**Name10 (NameIs) **] [**Name6 (MD) **] [**Name8 (MD) 19840**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-9-3**] 3:00 (resident working with Dr. [**Last Name (STitle) 5263**]
.
Blood count check next week.
ICD9 Codes: 5789, 2851, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4401
} | Medical Text: Admission Date: [**2121-12-23**] Discharge Date: [**2121-12-28**]
Date of Birth: [**2056-5-19**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: 65-year-old male with left upper
lobe lung cancer. He developed hemoptysis, and chest x-ray
revealed a mass. He underwent mediastinoscopy/Chamberlain
and negative nodes. Follow-up CT [**12-1**] revealed 3 and 5 cm
left upper lobe masses. Now presents for left upper
lobectomy.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post catheterization on
[**2121-10-29**]; [**11-5**] echocardiogram shows an ejection fraction of
greater than 55%; catheterization showed two vessel disease,
six stents to right coronary artery/mid-right coronary artery
dissection. Myocardial infarction [**11-27**] with troponin-i at
12.3.
2. Peripheral vascular disease status post aortobifemoral,
[**2-/2118**] by Dr. [**Last Name (STitle) **]; right femoral-popliteal in [**2111**]; toe
amputations; renal artery graft during aortobifemoral
3. Type 2 diabetes
4. Hypertension
5. Gastroesophageal reflux disease
6. Hypercholesterolemia
7. FEV-1 of 3.26, which is 96% of normal
LABORATORY DATA: Hematocrit 31.3, INR 1.2, creatinine 1.
Liver function tests negative.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.7, pulse
69, respiratory rate 16, blood pressure 150/60, oxygen
saturation 100% on room air. Cardiovascular: Regular rate
and rhythm. Pulmonary: Clear to auscultation. Abdomen:
Soft, nontender, nondistended. Extremities: Warm, with
palpable femoral pulses bilaterally.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2121-12-23**], at which time a left upper lobectomy and
mediastinal lymphadenectomy was performed. The patient
postoperative had complaints of vague chest pain, at which
time an electrocardiogram was checked and was found to be
normal, unchanged from baseline.
On early postoperative day one, the patient was found to have
decreased urine output, which did not respond to 250 cc
normal saline bolus. The patient dropped his blood pressure,
at which time the epidural was stopped. The patient
subsequently received one unit of blood for a hematocrit of
23, and a liter of crystalloid, and a dopamine infusion of 2
mcg/kg/minute was started. An electrocardiogram at that time
revealed non-ST elevation myocardial infarction. Enzymes
were cycled, which showed an increase in the CK/MB as well as
the troponin-i.
The patient was transferred to the Intensive Care Unit, where
he continued to do well enough so that the dobutamine drip
was weaned off. The patient was transfused with another unit
of packed red blood cells. A Cardiology consult was
obtained, which suggested Plavix for one year, as well as
agreeing with the current management.
The patient continued to do well in the Intensive Care Unit,
and was subsequently transferred in stable condition with a
stable blood pressure of 140, heart rate of 72, and oxygen
saturation of 92%, the patient was transferred to the
Surgical floor.
On the Surgical floor, intense pulmonary toilet was
continued, as well as good pain control. On postoperative
day four, the patient continued to do well, and subsequently
the following day, the patient was discharged to home on
[**2121-12-28**].
CONDITION AT DISCHARGE: Good
DISCHARGE STATUS: To home
DISCHARGE DIAGNOSIS:
1. Lung cancer in the left upper lobe
2. Non-ST elevation myocardial infarction
FOLLOW-UP PLANS: Follow up with cardiologist in one week.
Follow up with Dr. [**Last Name (STitle) 175**] in two weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg twice a day
2. Zestril 40 mg once daily
3. Hydrochlorothiazide 25 mg once daily
4. Norvasc 2.5 mg twice a day
5. Protonix 40 mg by mouth once daily
6. Lipitor 40 mg by mouth once daily
7. Plavix 75 mg by mouth once daily
8. Dilaudid 4 to 8 mg by mouth every four to six hours as
needed for pain
9. Colace 100 mg by mouth twice a day
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2121-12-28**] 21:33
T: [**2121-12-29**] 00:36
JOB#: [**Job Number 26073**]
ICD9 Codes: 9971, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4402
} | Medical Text: Admission Date: [**2178-4-24**] Discharge Date: [**2178-5-1**]
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
left groin pain
Major Surgical or Invasive Procedure:
excision of L graft, oversewing of CFA/graft stump [**4-25**]
insertion of PICC line [**5-1**]
History of Present Illness:
84 F with past severe vascular disease s/p aorto-bifem
bypass, bilateral above-knee amputations, resection of left
femoral pseudoaneurysm on [**2178-2-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital3 8834**] that was complicated by wound
infection treated with antibiotics now represented with left
groin pain. She was evaluated at M-WH and found to have a
recurrence of pseudoaneurysm in setting of leukocytosis (WBC
19).
She was subsequently transferred to [**Hospital1 18**] for further
management.
Patient is a vague historian but states that her left groin pain
began upon waking this morning. It did not radiate anywhere. She
did not experience any trauma and does not recall having
swelling
there but states that this area is "hard to see and she wouldn't
know if it has been there."
Past Medical History:
severe atherosclerotic disease/PVD, HTN, Myocardial
infarction, [**12-9**]: Infected PTFE graft left leg, aorto-bifem bpg
'[**72**], multiple R fem-[**Doctor Last Name **] operations culminating in R AKA,
multiple L fem-[**Doctor Last Name **], fem-tibial operations culminating in L AKA,
repair of L femoral pseudoaneurysm [**2178-2-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Hospital1 **]) with bovine patch and sartorius flap (with
assistance of balloon occlusion of inflow during procedure).
Social History:
NC
Family History:
NC
Physical Exam:
VS: 98.1 HR 78 BP 118/74 RR 20 O2 Sat 98% RA
Alert and oriented x2. Hard of hearing. Poor recollection of
medical history. Appropriate and comfortable
Neck supple. Pulses symmetric. No bruits
CV: RRR S1 S2 nl.
Pulm: clear
Abd: well healed lower midline incision. Non-distended,
non-tender. + BS.
Ext: Well healed b/l AKA. Left groin with healed incision. Large
pulsatile mass, mildly tender to palpation. Some mild blanching
erythema with discoloration. No drainage or appreciable
fluctuance.
Radial pulses intact b/l
Pertinent Results:
[**2178-4-25**] 9:44 am TISSUE LEFT FEMORAL GRAFT.
**FINAL REPORT [**2178-4-29**]**
GRAM STAIN (Final [**2178-4-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2178-4-28**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 2:25PM [**2178-4-27**].
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2178-4-29**]): NO ANAEROBES ISOLATED.
[**2178-4-24**] 12:35AM BLOOD WBC-16.6* RBC-4.07* Hgb-12.0 Hct-36.7
MCV-90 MCH-29.5 MCHC-32.7 RDW-15.1 Plt Ct-427
[**2178-4-24**] 12:35AM BLOOD PT-12.9 PTT-26.8 INR(PT)-1.1
[**2178-4-24**] 12:35AM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-136
K-3.6 Cl-99 HCO3-29 AnGap-12
[**2178-4-24**] 12:35AM BLOOD estGFR-Using this
[**2178-4-24**] 12:35PM BLOOD ALT-12 AST-14 AlkPhos-104 TotBili-0.3
[**2178-4-24**] 12:35PM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.3 Mg-2.1
[**2178-4-30**] 08:35AM BLOOD WBC-13.0* RBC-3.64* Hgb-10.8* Hct-33.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-15.4 Plt Ct-792*
[**2178-4-30**] 08:35AM BLOOD Plt Ct-792*
[**2178-5-1**] 09:00AM BLOOD Glucose-195* UreaN-15 Creat-0.8 Na-133
K-4.6 Cl-101 HCO3-24 AnGap-13
[**2178-5-1**] 09:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.8
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment. The patient was admitted for graft excision on HD
2. Mrs. [**Known lastname **] was discharged to an extended stay facility on
POD 6.
Neuro: The patient received prn pain meds with good effect and
adequate pain control. The patient was complaining of phantom
leg pain on POD 4 and received IV morphine and her neurontin was
increased to 600mg TID.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. The patient was stable on
his medications of diltiazem and statin medication.
Pulmonary: Mrs. [**Known lastname **] was successfully extubated
postoperatively. The patient was stable from a pulmonary
standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was able to eat a regular, lactose
reduced diet.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient was started on Vancomycin and Zosyn on admission
for her graft infection. The patient's white blood count and
fever curves were closely watched for signs of infection. The
patient's wound and graft grew out pseudomonas and the patient
was changed to an antibiotic regimen of vancomycin, cefepime and
ciprofloxacin. She was discharged on a 2 week course of
vancomycin and cefepime. The ciprofloxacin will be a daily
medication.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and 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 with assistance, voiding without assistance,
and pain was well controlled.
Medications on Admission:
Diltiazem 180, [**Last Name (LF) 11346**], [**First Name3 (LF) **] 325, Fluoxetine 10, Folic Acid 1,
Gabapentin 300 [**Hospital1 **], Seroquel 12.5, Thiamine 100, Trazodone 50,
MVI, Vit C 500, Zinc 220,
Azithro 250 from [**Date range (1) 62721**] for ? pneumonia.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Insulin Regular Human Injection
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) dose Inhalation Q6H (every 6 hours) as needed.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Vascular Disease.
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain.
15. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous once
a day for 2 weeks.
17. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 2 weeks.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) **]
Discharge Diagnosis:
peripheral vascular disease
hypertension
Myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
WHAT TO EAT AND DRINK THE NIGHT BEFORE YOUR PET/CT SCAN & HOW TO
TAKE THE SPECIAL PREPARATION (CLEARSCAN)
The night before your scan at your regular dinnertime eat a high
fat, high protein no carbohydrate dinner. Avoid sugars
(glucose, fructose, sucrose, etc) until after your scan.
Your choice of dinner can include:
Fatty unsweetened foods (fried in butter or olive oil, broiled,
but not grilled):
Chicken, [**Country 1073**], fish,
meats (steak, ham etc),
meat only sausages, fried eggs, bacon, scrambled eggs prepared
without milk, omelet prepared without milk or vegetables, fried
eggs and sausages,
fried eggs and bacon, hotdogs (plain -without the bun),
hamburgers (plain - without the bun or vegetables)
You should not eat any food containing carbohydrates and sugars,
(and Splenda). Please do not eat the following foods:
Milk, cheese, bread, bagels, cereal, cookies, toast, pasta,
crackers, muffins, peanut butter, nuts, fruit juice, potatoes,
candy, fruit, rice, chewing gum, mints, cough drops, vegetables,
beans, alcohol
You should drink clear liquids without milk or sugars
Diet Pepsi or Diet Coke
Coffee without milk or sugar
Can use sweet n?????? low, nutra-sweet or equal
Tea without milk or sugar
Water
For an AFTERNOON appointment (after 1pm):
Eat this breakfast 3 ?????? 5 hours before your scan, nothing to eat
after breakfast.
BEFORE YOUR SCAN
You may drink water up to the time of your scan. Use only
water to take your medications.
Followup Instructions:
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2178-5-14**] 2:00, [**Hospital Ward Name 2104**] Bldg, [**Location 78342**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2178-5-14**] 2:00, [**Hospital Ward Name 2104**] Bldg, [**Location 78342**]
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2178-5-18**] 12:15 [**Hospital Unit Name **] [**Location (un) 442**]
([**Telephone/Fax (1) 1504**] Dr [**Last Name (STitle) 78343**]
[**1670-5-18**], Office Visit, [**Hospital Ward Name 23**] 9
PET Scan - ([**Telephone/Fax (1) 9595**], [**1520-5-11**], PET SCAN, [**Hospital Ward Name 23**] Bl
You have a MRI of the head. You are scheduled for one on [**5-5**] 1415 hrs. [**Telephone/Fax (1) 327**]. [**Location (un) **] [**Hospital Ward Name 23**] Building
ICD9 Codes: 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4403
} | Medical Text: Admission Date: [**2125-8-7**] Discharge Date: [**2125-8-10**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
dry mouth, feeling "dehydrated"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 yo female with type I DM, diagnosed 4 years ago, with
multiple admissions for DKA in the recent past. She was admitted
to [**Hospital3 1810**] from [**Date range (1) 58214**] with DKA. Now
returns to [**Hospital1 18**] ED with c/o "dry mouth" and dehydration.
The patient was seen at the [**Hospital1 **] ER on [**2125-7-26**] with
complaints of vaginal pain/itching/dysuria and was diagnosed
with genital herpes that was treated with acyclovir. Denies
fever/chills; + persistent but improved vaginal pain, no
dizziness, LH, + vomiting on admission, no cough, no abd pain,
no diarrhea, constipation. Denies being pregnant.
In the ER on admission: Exam significant for dry MM, vaginal
exam showing ? white d/c in vagina (no KOH/wet mount done); labs
sig for wbc=11.1 with 85% neutrophils, FS 400s, UA ketones 150,
few bacteria, K=5.4, Cr=1.3, bicarb=11 with AG + 33. Cxr
negative for pna. Given IVF and started on insulin drip.
Past Medical History:
1. Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
2. Hyperlipidemia
3. S/P MVA [**5-4**] - lower back pain since then. + back muscle
spasm treated with tylenol.
4. Goiter
5. Depression
6. DKA admissions
7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p
C-section in [**2122**], not menstruating secondary to being on
Depo-Provera shots
Social History:
Completed high school in [**2122**]. She has a two-year-old son with
her current partner. [**Name (NI) 1139**]: [**12-1**] ppd x 3 years. No EtOH. No
marijuana, cocaine, heroin or other recreational drugs.
Unemployed. Sexually active. 4 life partners. Currently
monogamous over 1 year.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
T 98.8 98/53 83 18 100% RA
General: A&Ox 3, NAD
HEENT: NC, AT, EOM intact, sclera white, conjunctiva pink,
PERRLA, MMM
CV: Regular, no m/g/r
Pulm: CTA bilaterally
Abd: +BS, soft, tender to palpation in RUQ, no rebound, no
guarding, liver edge palpable 3-4 cm below RCM, no SM
Back: no CVA tenderness, mild lumbar tenderness to percussion
(chronic since her MVA)
Extr: no c/c/e
Pelvic (per ER): white discharge, no CMT, no adnexal tendernes
Pertinent Results:
[**2125-8-7**] 04:17PM BLOOD WBC-11.1*# RBC-4.71 Hgb-14.0 Hct-43.5#
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.3 Plt Ct-255#
[**2125-8-7**] 04:17PM BLOOD Plt Ct-255#
[**2125-8-7**] 04:17PM BLOOD Neuts-84.9* Bands-0 Lymphs-12.3*
Monos-1.3* Eos-1.1 Baso-0.3
[**2125-8-10**] 05:38AM BLOOD WBC-4.9 RBC-3.76* Hgb-11.1* Hct-33.5*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.7 Plt Ct-181
[**2125-8-10**] 05:38AM BLOOD Plt Ct-181
[**2125-8-7**] 04:17PM BLOOD Glucose-686* UreaN-20 Creat-1.3* Na-134
K-6.1* Cl-90* HCO3-11* AnGap-39*
[**2125-8-10**] 05:38AM BLOOD Glucose-298* UreaN-7 Creat-0.6 Na-137
K-4.6 Cl-103 HCO3-24 AnGap-15
[**2125-8-7**] 04:17PM BLOOD ALT-18 AST-32 LD(LDH)-412* AlkPhos-102
Amylase-42 TotBili-0.6
[**2125-8-8**] 04:43PM BLOOD ALT-11 AST-13 LD(LDH)-91* AlkPhos-70
Amylase-57 TotBili-0.3
[**2125-8-7**] 04:17PM BLOOD Lipase-31
[**2125-8-7**] 04:17PM BLOOD Albumin-5.3* Calcium-11.0* Phos-7.7*#
Mg-2.4
[**2125-8-10**] 05:38AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8
[**2125-8-7**] 11:02PM BLOOD Acetone-LARGE
[**2125-8-8**] 06:36AM BLOOD Acetone-MODERATE
[**2125-8-9**] 12:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2125-8-7**] 04:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.027
[**2125-8-7**] 04:17PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2125-8-7**] 04:17PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**8-7**] EKG: no ischemic changes
[**8-7**] CXR: No evidence of pneumonia.
[**8-7**] US: Normal abdominal ultrasound.
Brief Hospital Course:
20 yo female with DM type I admitted with DKA.
1. DKA - The patient was initially admitted to the intensive
care unit. She was started on insulin drip and was hydrated with
NS until her blood glucose was below 200. Then her IV fluid were
changed to D51/2 NS with potassium. Insulin drip was
discontinued when that patient's AG closed and she was continued
on sc insulin per sliding scale. No clear precipitating factor
for her repeated DKA could be identified. The patient had no
evidence of infection except for her recent HSV infection (CXR,
UA were both negative, pelvic exam WNL with negative GC/Chlam).
Endocrinology was consulted. They recommended to continue the
patient on Glargine 28 units qam and carbohydrate counting
(Humalog 1 unit per 10 grams carbohydrates) for her outpatient
regimen. The patient was discharged home in improved condition.
She tolerated po well on the day of and the day prior to
discharge. She received prescriptions for insulin (Glargine and
Humalog), ultra fine needles, Ketostix and glucagon emergency
kit. She was instucted to go directly to [**Last Name (un) **] Diabetes Center
for her appointment with a nurse practitioner at 11 am on the
day of discharge.
2. RUQ tenderness - RUQ US was normal. Hepatitis serologies,
LFTs and amylase, lipase were all within normal limit.
Outpatient follow up is recommended.
3. Genital hepres infection, treated - Because of concern that a
pelvic infection may be a precipitant for repeated DKA episodes
in this patient, pelvic examination was performed in the
emergency room and a cervical swab for GC and Chlamydia was
done. Both cultures came back negative. The patient received a
Depo-Provera injection prior to discharge (pregnancy test at
[**Hospital1 **] negative, patient denied being pregnant). She was
counseled regarding barrier methods for protection against
sexually transmitted diseases.
The patient was discharged in improved condition. She will
follow up at [**Last Name (un) **] Diabetes Center and with her PCP at [**Name9 (PRE) 17377**]
[**Name9 (PRE) **] Clinic.
Medications on Admission:
Home meds:
Lipitor 20 po qd
Lantus 30 hs
Novolin 1 unit/10 gram carbs
Depo-Provera
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Insulin Glargine 100 unit/mL Solution Sig: 0.3 ml
Subcutaneous qam.
Disp:*100 ml* Refills:*0*
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit
per 10 gm carbohydrates Subcutaneous as directed: 1 units of
insulin (0.01 ml) per 10 gm of carbohydrates.
Disp:*100 ml* Refills:*2*
5. supplies
Ketostix please give 1 box
Please check your urine for ketones every time your blood
glucose >250 or if you have nausea. Call your physician or go to
the emergency room if ketostix test is positive.
6. Insulin Syringe Ultra Fine II Syringe Sig: One (1) box
Miscell. as directed.
Disp:*1 * Refills:*2*
7. Glucagon Emergency 1 mg Kit Sig: One (1) Injection as
directed: Please have with you at all times. Please use
immediately when you blood sugar is below 50. .
Disp:*10 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diabetic Ketoacidosis
Discharge Condition:
improved
Discharge Instructions:
Please keep your follow up appointments with [**Last Name (un) **] Center as
below.
Please take 28 units of Glargine every morning at 8am.
Please continue to take Humalog insulin 1 units:10
carbohydrates.
Please keep your glucagon emergency kit with you at all times in
case you have low blood glucose.
Please check your urine for ketones with Ketostix every time
your blood glucose is >250 or if you have nausea or suspect that
you may have DKA again. Please call your physician or see [**Name Initial (PRE) **]
[**Location (un) **] care provider if the test is positive for ketones.
Followup Instructions:
Please see a nurse practitioner today, [**2125-8-10**] at 11
am at [**Last Name (un) **] Diabetis Center.
Please call ([**Telephone/Fax (1) 17612**] to schedule an appointment to address
your health care needs.
Completed by:[**2125-8-12**]
ICD9 Codes: 2765, 3051, 311, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4404
} | Medical Text: Admission Date: [**2180-5-17**] Discharge Date: [**2180-5-26**]
Date of Birth: [**2180-5-17**] Sex: M
Service:
DISCHARGE DIAGNOSES:
1. Premature male infant (twin II) at 34 and 5/7 weeks
gestation.
2. Status post mild transient tachypnea .
3. Hyperbilirubinemia.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] is the 34 and [**4-5**] week
2.230 kilogram twin II born to a 37-year-old primigravida
whose prenatal screens reveal she is B positive, and the
remaining were noncontributory.
The mother's past medical history was notable for depression
(on fluoxetine 20 mg per day).
The pregnancy was accomplished by in [**Last Name (un) 5153**] fertilization,
dichorionic-diamniotic twins, complicated by cervical
shortening, treated with bed rest from 24 weeks gestation.
In the week prior to delivery severe oligohydramnios was
noted in twin I leading to induction. Rupture of membranes
occurred at 3.5 hours prior to delivery. There was no
maternal intrapartum fever, clinical chorioamnionitis or
fetal tachycardia. Intrapartum antibiotics were administered
three hours prior to delivery. The infant were delivered
vaginally. Apgar scores of this baby were 5 at one minute
and 8 at five minutes.
On admission, the infant weighed 2.23 kilograms, head
circumference was 33 cm, and length was 43 cm; all
appropriate for gestational age.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant initially presented with
some grunting and tachypnea; however, this resolved within
the first day of life, and there were no further
respiratory issues. He remained on room air throughout his
hospital stay. There were no episodes of apnea or
bradycardia of prematurity.
2. CARDIOVASCULAR SYSTEM: There were no cardiac issues.
3. INFECTIOUS DISEASE ISSUES: The infant was initially
placed on ampicillin and gentamicin for 48 hours because of
occasional grunting of respirations. His ampicillin and
gentamicin were discontinued at 48 hours with negative blood
cultures and a benign complete blood count.
4. HEMATOLOGIC ISSUES: Mother was B positive. The infant
had an admission hematocrit of 57.7 and a peak bilirubin of
12.2 (for which he underwent phototherapy for several days).
His rebound bilirubin was 9.9.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: At the time of
discharge, the infant weighed 2.30 kilograms, was feeding ad
lib demand with two breast feedings per day. He was being
fed mother's mild 24-calories per ounce or Enfamil
24-calories per ounce.
6. AUDITORY ISSUES: Hearing screen performed on [**5-24**] and
was passed.
7. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine given on
[**5-21**].
DISCHARGE STATUS/RECOMMENDATIONS: The infant was to be
discharged home on Enfamil 24 or mother's mild 24. When
baby's are fully on mother's milk, pediatrician can initiate
vitamin and iron supplements.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The infant will be followed
at [**Hospital1 **] Center by Dr. [**Last Name (STitle) 47858**]. They will be seen
on [**5-29**]. [**Hospital6 407**] to come to home on
the day following discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 38370**]
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2180-5-25**] 09:53
T: [**2180-5-25**] 09:55
JOB#: [**Job Number 47860**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4405
} | Medical Text: Admission Date: [**2181-6-7**] Discharge Date: [**2181-6-19**]
Date of Birth: [**2102-11-4**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
weakness, fever
.
Major Surgical or Invasive Procedure:
Central line
s/p fiberoptic intubation
History of Present Illness:
This is a 78 year old man with a history of multiple CVAs with
right side weakness who presented to the ED on [**2181-6-8**]
complaining of weakness x 3 days. He also complained of
abdominal pain which he has had in the past with a negative
workup. He denied N/V/D.
.
In the ED, abdominal CT scan revealed some diverticulosis but
otherwise no explanation for his abdominal pain. He had a fever
to 101.1 in the ED and was admitted to Medicine for workup of
his weakness/fever/abdominal pain.
In the ED, he was started on empirical levo and flagyl and blood
cultures were drawn. a U/A, and CT abdomen/pelvis were
negative. CXR showed mild fluid overload and enlarged heart,
and CT of his head was neg for new pathology. He had a neuro
consult that demonstrated no neurological changes from baseline.
The patient had a ground level fall in the ED, and a repeat CT
scan of the head showed no bleeding.
Past Medical History:
hypertension
s/p CVA (mulitple, large R ischemic CVA, multiple small CVAs in
white matter)
h/o HOCM by last echo
seizures
hyperlipidemia
s/p hip fracture
anemia
? hx of hyperglycemia
Chronic low back pain s/p laminectomy
migraines
depression
Social History:
-lives with wife
-smokes one cigar per day
-no alcohol use
-worked in sales
Family History:
-both parents with CAD
Physical Exam:
VS:T:99.0 BP:130/82 HR:80 RR:16 O2sat:95%RA
gen: mildly confused elderly man in NAD. difficulty sitteing up
on own
HEENT: EOMI, PERRLA, some L facial droop. Oropharynx: mild
erythema
Ears: TMs clear bilaterally. Some erythema in canal in R ear.
Neck: no JVD
Chest: Lungs CTA
Heart: distant heart sounds, RRR, no murmur
Abd: soft, non-distended, +BS, mildly tender to palpation
periumbilical. No rebound, no guarding, no hepatosplenomegaly.
Ext: [**4-13**] motor strength in all extremities.
Decreased DTRs L side. Mild facial drop L side.
Pertinent Results:
CT head:No evidence of intracranial hemorrhage or mass effect.
Chronic changes. Stable appearance compared to [**2181-5-14**].
CT A/P:Diverticulosis without evidence of diverticulitis. No
explanation seen for the patient's acute abdominal pain
KUB: Normal bowel gas pattern without evidence of obstruction.
CXR:Mild CHF/volume overload. No evidence of pneumonia
CT chest:
1. No evidence of pulmonary embolism or aortic dissection.
2. Small bilateral pleural effusions and associated bibasilar
atelectasis. The effusions are new since the prior chest CT in
[**2179**].
3. Coronary arterial calcification. The study was not
performed using gated technique.
ECHO:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy with normal cavity size
and hyperdynamic systolic function (EF>75%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). There is systolic anterior motion of the mitral
valve leaflets with a moderate resting left ventricular outflow
tract obstruction (peak 54mmhg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
moderately thickened. Severe aortic stenosis is not suggested,
but mild aortic stenosis cannot be excluded/possible. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
a a very small anterior pericardial effusion with a prominent
epicardial fat pad. No hemodynamic compromise is suggested.
CT neck: Suboptimal study due to the artifacts from the teeth.
No evidence of parotid abscess/stones. Evidence of inflammation
in the soft tissues of the neck.
.
[**2181-6-6**] 03:35PM PT-11.3 PTT-23.3 INR(PT)-1.0
[**2181-6-6**] 03:35PM PLT COUNT-131*
[**2181-6-6**] 03:35PM WBC-6.7 RBC-4.10* HGB-13.9* HCT-40.3 MCV-98
MCH-33.9* MCHC-34.5 RDW-13.1
[**2181-6-6**] 03:35PM cTropnT-<0.01
[**2181-6-6**] 03:35PM ALT(SGPT)-20 AST(SGOT)-33 ALK PHOS-85
AMYLASE-41
[**2181-6-6**] 03:35PM GLUCOSE-103 UREA N-18 CREAT-1.0 SODIUM-139
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2181-6-6**] 09:40PM cTropnT-<0.01
[**2181-6-7**] 05:00PM CK(CPK)-74
Brief Hospital Course:
# Angioedema/ airway compromise: While on the floor, the pt's
throat and cheeks and neck began to swell. Two days later, on
[**2181-6-10**], his blood pressure dropped to 50/palp. He was given 3L
NS and his BP rebounded to the 80's. However, his O2 sats
dropped to 90% on 4L and he was transferred to the ICU for
further management of his hypotension/ hypoxia/ angioedema. A CT
of the neck was negative for abscess, however soft tissue
inflammation was seen. Pt's O2 requirement was felt to likely
related to airway compromise from severe facial/neck swelling.
He underwent fiber optic intubation for airway protection. He
was initially on AC which was weaned to PSV 5/5 and he was
successfully extubated on [**2181-6-14**] and comfortable on room air
prior to discharge to floor. In terms of his fever/facial
swelling, the differential included mumps, adeno, paraflu,
parotid duct obstruction, bacterial parotitis, or facial
cellulitis. Angioedema also possible given hx of lisinopril
(most likely cause), aspirin, and ibuprofen use, combined with
eosinophilia. His neck CT findings were not consistent with
enlarged parotid glands or severe facial cellulits; hence
angioedema seemed most likely. His lisinopril and ASA were
stopped because of their penchant (especially lisinopril) for
causing angioedema. ENT was also consulted and did not find any
obvious sources for his neck swelling. Steroids were held
because of concern for infectious etiology (though 1 dose was
given; ENT had felt that holding the steroids for use until
prior to extubation would be a better strategy).
Viral throat cx negative, strep throat cx negative. After his
initial neck CT, he had a repeat neck CT on [**6-12**] which showed new
stranding in the subcutaneous soft tissues of the posterior neck
and occiput consistent with edema. THere was also stranding of
soft tissues of the chest, slight stranding near the parotid
glands is stable, irregularity of opacification of the left
internal jugular vein (probably due to filling artefact as this
appears to occur near the entry point of an anterior venous
structure), and iterval opacification of the paranasal sinuses
with increasing mucosal thickening. Unclear [**Name2 (NI) 100410**] of these
findings, as diagnosis still remained uncertain. The filling
defect was not a thrombus as confirmed by US.
He was initially on steroids, but stopped per ENT as it was felt
that the effects of the steroids would be most useful to
decrease airway edema prior to extubation.
Allergy was consulted who felt that patient should not be
continued on lisinopril, but K to restart ASA and dipyridamole.
Per dental consult, tooth pathology likely not cause of pt's
neck swelling. With Diphenhydramine alone, the patient's edema
had started to resolve and his oxygenation and ventilation were
appropriate four days after intubate; hence he was extubated
without difficulty. On discharge C1 esterase inhibitor, Mumps
antibody and C2 was still pending.
.
# Hypotension: no clear etiology of the pt's hypotension during
the initial episode of neck swelling was found. The pt was
thought to be hypovolemic and he was thought to have increased
intrathoracic pressures due to airway obstruction from the
swelling. These two factors were thought to decrease the pt's
diastolic filling on which he was largly dependent given his
outflow obstruction in the context of HCOM. The pt was treated
with Nafcillin, Levo and Flagyl for five days, but antibtiotics
were subsequently discontinued as the pt was afebrile and all
cultures were negative and no clear source of infection was
found. THe pt remained afebrile for four days after
discontinuation of the antibiotics.
.
# Hypoxia: Pt's O2 requirement was felt to likely related to
airway compromise from severe facial/neck swelling. He underwent
fiber optic intubation for airway protection. He was initially
on AC which was weaned to PSV 5/5 and he was successfully
extubated on [**2181-6-14**] and comfortable on room air prior to
discharge to floor. On CXR, he was found to have a slightly
widened mediastinum; a chest CT ruled out dissection. Of note,
his CXR was also consistent with pulm edema, likely secondary to
aggressive IVF, but did not impair his oxygenation.
.
# Abdominal pain: no evidence of intrabdominal pathology on CT.
POssible in the context of angioedema. Resolved.
.
# Anemia: Pt hematocrit was trending down in the setting of
acute disease. Guaiac negative. No other source of bleeding.
Folate and Vit B12 normal. Iron studies consistent with anemia
of chronic disease. The pt's hct stabilized with improvement of
clinical status, although his reticulocyte count was not
adequate. The pt was not on any medications other then Depakote
that could explain his anemia, especially no marrow suppressive
medications. Further work up should be performed as an
outpatient if the pt persists to be anemic. F/u hct recommended
within one week.
.
# Seizures: Continued depakote. THe pt missed a few doses while
he was intubated which explains his transiently low valproic
acid level. Levels were rising as Depakote was restarted at home
dose. F/u level in one week is recommended to ensure adequate
levels.
.
# Rash: The pt developed a mild diffuse rash thought to be
secondary to antibiotics which was given when he was hypotensive
to treat for sepsis emperically. His rash improved after
withdrawing the antibiotics.
.
# Low back pain-chronic s/p laminectomy. Pt on oxycontin at
home, held in the context of hypotension. Not restarted upon
discharge as the pt was pain free.
.
# Code: full
Medications on Admission:
Ativan 1mg daily
depacote 500mg [**Hospital1 **]
gemfibrozil 600mg [**Hospital1 **]
atorvastatin 40mg daily
lisinopril 2.5mg daily
neurontin 300mg TID
oxycontin 10mg [**Hospital1 **]
zoloft 50mg daily
aggrenox 1 cap daily
Discharge Medications:
1. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Aggrenox 200-25 mg Cap, Multiphasic Release 12 HR Sig: One
(1) Cap, Multiphasic Release 12 HR PO twice a day.
Disp:*60 Cap, Multiphasic Release 12 HR(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO twice
a day for 7 days.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DX:
Angioedema of the throat, tongue and lip
Abdominal pain secondary to ?angioedema
Hypotension
Respiratory failure due to airway obstruction from angioedema
Anemia of chronic disease
.
SECONDARY DX:
Chronic low back pain
HCOM
Discharge Condition:
Hemodynamically stable, afebrile, out of bed with assistance.
Discharge Instructions:
Please take all medication as prescribe. Follow up with all
appointments. If you experience any more swelling or difficulty
breathing, please call your doctor. Also call your doctor if
you have chest pain or shortness of breath.
Please make sure you remove all Lisinopril from you medication
boxes. You should never again in your live take Lisinopril or
any medication from the same class.
Followup Instructions:
Follow up with your doctor in the week after discharge from
rehab: [**Last Name (LF) 10531**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 9347**].
.
Other appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2181-8-20**] 12:30
ICD9 Codes: 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4406
} | Medical Text: Admission Date: [**2179-3-8**] Discharge Date: [**2179-3-14**]
Date of Birth: [**2110-3-4**] Sex: F
Service: MEDICINE
Allergies:
Naproxen / Codeine / Aspirin / Oxycontin
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Patient expired.
History of Present Illness:
Mrs. [**Known lastname 10220**] is a 69 yo F with breast cancer with mets to
peritoneum on complicated by acites requiring 14 paracenteci
since [**9-2**], on navelbine/avastin C2D13 now presents wtih dyspnea
and poor po intake. Patient noticed increased DOE over the last
36 hours with increased labored breathing while walking around
the house and requiring assistance to even walk around the
living room. Patient also reports increased nausea with
vomitting 7-10 times over the last 2 days. Vomitius is
nonbilious, and patient has been unable to tolerate po intake.
Patient often has diarrhea related to Chemo, but reportedly no
diarrhea since Tuesday. Patient was seen by VNA today and BP was
60/p. EMS was called and on arrival BP was 80/p.
.
In the ED, patient was noted to be hypotensive on arrival but
improved with 3 L NS. Inital resident echo was concerning for
pericardial effusion with collapse of RV, but formal TTE by
Cardiology fellow showed no evidence of tamponade. LENIS were
negative for DVT. CT head was negative. CXR was unremarkable.
Vanco/Zosyn was given for initial concern of sepsis. Lytes were
noteable for Na 117 down from 122 earlier in the month and Cr
2.2 from 0.8. Also noted to be neutropenic. Patient refused
central line and code status was reportedly DNR/I.
.
On the floor, patient reports chronic low back pain, and feels
weak and fatigued, but otherwise feels well.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. 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,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Medical History:
Breast cancer
- Diagnosed in [**2174**] with an infiltrating lobular carcinoma grade
II, 1.7 cm, multifocal, with 13 out of 29 lymph nodes positive.
The tumor was ER positive, PR positive, and HER-2/neu negative
by both IHC and FISH. She underwent adjuvant chemotherapy after
completion of surgery with Adriamycin and Cytoxan followed by 10
weekly doses of Taxol. She received and completed chest wall
radiation. She was then started on adjuvant Arimidex therapy. In
[**2178-1-25**] she developed right shoulder pain and pain in her
upper abdomen. The abdominal pain prompted workup and apparently
blood work showed a CA [**95**]-29 level of 203. A PET scan revealed
nodularity in her omentum consistent with metastatic disease. A
bone scan reportedly was negative. She was started on high-dose
Faslodex hormone treatment [**2178-3-12**] and progressed on this
in [**2178-7-25**]. She was started on Xeloda in [**8-/2178**] and
continued and recently progressed with her last dose of Xeloda
on [**2178-12-5**].
- S/p Fulvestrant x7 last given [**2178-9-16**]
- Temodar PARP Phase II Trial: Cycle #: 1 Day 1: [**2179-1-13**], went
off trial for for toxicity
- VinORELbine (Navelbine) 40 mg IV day 1 ([**2179-1-21**]), held day 8
and 15 due to neutropenia. (30 mg/m2 - dose reduced by 17% to 25
mg/m2)
.
Other Past Medical History:
1. Breast cancer as above
2. Bladder suspension.
3. GERD
4. Osteoporosis.
5. Left frozen shoulder.
6. Depression and anxiety.
7. Laparoscopic cholecystectomy.
8. Rosacea.
9. Hypothyroidism.
10. Sleep apnea.
11. Rheumatic fever with subsequent dental prophylaxis.
12. Left eye surgery.
Social History:
She is divorced. She is a nonsmoker and drinks alcohol socially.
She is retired and former employee of the Federal government.
She is of Lithuanian origin.
Family History:
Her mother had breast cancer at age 75 and underwent lumpectomy
and radiation therapy. Her maternal aunt had [**Name2 (NI) 499**] cancer in
her 70s. The patient's sister had [**Name2 (NI) 499**] cancer at 55 and two
paternal aunts with breast cancer at age 52 and 70, a paternal
first cousin had renal cancer. She has not undergone genetic
testing.
Physical Exam:
Vitals: T: 96.5 BP: 100/58 P: 116 R:18 O2: 97% 2L NC
General: Markedly cachectic, tired appearing, pale, but NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear without thrush
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema of ankles
bilaterally, no clubbing, cyanosis
Pertinent Results:
[**2179-3-8**] 04:20PM BLOOD WBC-1.1*# RBC-3.85* Hgb-12.3 Hct-34.8*
MCV-91 MCH-32.0 MCHC-35.4* RDW-14.5 Plt Ct-270
[**2179-3-9**] 12:28AM BLOOD WBC-1.0* RBC-3.46* Hgb-11.2* Hct-32.3*
MCV-93 MCH-32.4* MCHC-34.7 RDW-14.4 Plt Ct-292
[**2179-3-9**] 04:20AM BLOOD WBC-1.0* RBC-3.40* Hgb-10.8* Hct-31.3*
MCV-92 MCH-31.9 MCHC-34.6 RDW-14.7 Plt Ct-268
[**2179-3-10**] 03:04AM BLOOD WBC-1.2* RBC-3.30* Hgb-10.2* Hct-30.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.8 Plt Ct-311
[**2179-3-9**] 12:28AM BLOOD PT-11.3 PTT-34.4 INR(PT)-0.9
[**2179-3-8**] 04:20PM BLOOD Glucose-100 UreaN-115* Creat-2.2*#
Na-117* K-4.3 Cl-71* HCO3-30 AnGap-20
[**2179-3-9**] 04:20AM BLOOD Glucose-95 UreaN-88* Creat-1.5* Na-126*
K-3.6 Cl-86* HCO3-29 AnGap-15
[**2179-3-10**] 03:04AM BLOOD Glucose-96 UreaN-71* Creat-1.1 Na-130*
K-3.4 Cl-93* HCO3-27 AnGap-13
[**2179-3-9**] 04:20AM BLOOD CK(CPK)-18*
[**2179-3-9**] 02:37PM BLOOD CK(CPK)-18*
[**2179-3-10**] 03:04AM BLOOD CK(CPK)-16*
[**2179-3-9**] 04:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2179-3-9**] 02:37PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-10**] 03:04AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-8**] 04:20PM BLOOD proBNP-4631*
.
[**3-8**] Echo:
Overall left ventricular systolic function is normal (LVEF>55%).
Due to suboptimal image quality and focused views, a focal wall
motion abnormality cannot be excluded.. Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is a very small
pericardial effusion, primarily around the right atrium and
basal right ventricle with no echocardiographic signs of
tamponade.
.
[**3-8**] CXR:
(pending final read)
.
[**3-8**] LENIs:
IMPRESSION: No evidence of DVT of either lower extremity.
.
[**3-8**] Head CT:
IMPRESSIONS: No acute intracranial abnormality. No evidence of
intracranial mass, but MRI is more sensitive for the detection
of intracranial lesions and should be considered.
[**3-10**]: KUB
Moderate amount of ascites with largest pocket seen within the
right lower quadrant. Multiple septations are noted compatible
with component
of loculation of the fluid.
[**3-12**]: Request for Pleurx catheterization for palliative
peritoneal ascites drainage.
1. Successful placement of Pleurx catheter in the right abdomen,
with the tip
terminating in the lower pelvis.
2. Removal of one liter of yellow ascites fluid.
.
[**2179-3-13**] 05:23PM BLOOD WBC-5.4 RBC-3.37*# Hgb-10.6*# Hct-33.4*#
MCV-99* MCH-31.4 MCHC-31.8 RDW-14.5 Plt Ct-434
[**2179-3-13**] 05:12AM BLOOD Glucose-86 UreaN-73* Creat-1.3* Na-145
K-4.1 Cl-114* HCO3-22 AnGap-13
[**2179-3-13**] 05:23PM BLOOD LD(LDH)-132 TotBili-1.0 DirBili-0.4*
IndBili-0.6
[**2179-3-13**] 05:12AM BLOOD Calcium-10.2 Phos-3.5 Mg-1.9
[**2179-3-11**] 02:48PM BLOOD CA27.29-744*
[**2179-3-8**] 04:32PM BLOOD Lactate-1.6 K-4.1
Brief Hospital Course:
Patient expired.
69 yo F with metastatic breast cancer prsents with vomitting,
poor po intake and dyspnea and to be in acute renal failure with
hyponatremia. Was tachycardic and complaining of mild chest
tightness. Admitted to the ICU for tachycardia and
hyponatremia, then to the oncology floor. See below for
discussion of each issue.
.
Goals of care: meeting in ICU regarding goals of care and poor
prognosis, then reiterated on the oncology medicine floor:
Code: DNR/I (discussed with patient and HCP), and daughter HCP
[**Name (NI) **] [**Telephone/Fax (1) 80568**]. Focus on comfort with symptom management.
Avoidance of invasive procedures, per family (son, daughter,
sister).
[**Name2 (NI) **] died the morning after being transferred to the ICU.
.
# Altered mental status: Patient does not respond to verbal or
visual stimuli on the floor. Likely d/t progressive metastatic
disease, combined with renal failure, hypotension, pain, SBP
infection, delirium. Pain controlled with IV morphine prn,
treated SBP with ceftriaxone, palliative care following.
.
# Chest Pain: unclear etiology, seemed to be costrochondritis
related as the pain was reproducible. Ruled out for MI with
three sets of negative cardiac enzymes. A V/Q of her chest was
ordered to rule out PE, but the patient was unable to lie flat
and complete the exam so it was aborted. Held anticoagulation
d/t goals of care, no CTA given ARF, could not tolerate V/Q
scan. On the floor, patient unable to verbalize whether chest
pain still present. Pain medications provided.
.
# Hypotenion/Tachycardia: likely was related to underlying
cancer and hypovolemia. Was volume resuccitated with NS and the
LR while in the ICU for the first two days. She was offerred a
CVL in the ED and declined. Her BP improved to SBPs in the 90s,
then 100s with IVFs and remained stable. Initially she seemed
fluid responsive with a decrease in rate from 130s to 110s
(which seemed to be her baseline). She remained tachycardic on
day two of admission without an obvious cause as she seemed
mostly fluid repleted. We continued to bolus her and pursued a
further workup for PE. Initially she had negative LENIs and a
CT was deferred because of ARF. A V/Q scan was performed on
[**2179-3-10**], but she was unable to lie flat for the test and the
test could not be completed. She was bolused periodically
overnight to maintain MAP of over 65. Her tachycardia improved
with IVF boluses prn.
.
# Hyponatremia/Acute renal failure: Based on exam and history,
likely hypovolemic hyponatremia. Most likely Gi losses combined
with third spacing in the setting of ascites. With fluid
resuccitation, she corrected and normalized very quickly but did
not have any neurological changes. She did have a CT head in
the ED that showed no intracranial lesions to explain this. Her
ARF also improved with IVFs and her urine output remained brisk
throughout her hospitalization.
.
# Thrush: Likely due to poor po intake and nausea/vomitting.
Started swish and swallow for her comfort.
.
# Breast Cancer: mid-cycle in her avastin and navelbine. Is
metastatic and has recurrent ascites requiring taps. On
presentation, her abdomen was soft and a therapeutic
paracentesis was deferred because of her hypovolemia, moderate
hypotension and neutropenia. Oncology was consulted and
followed along. Patient to oncology floor, outpatient oncology
attending described poor prognosis. Family meeting regarding
poor prognosis and goals of care; patient not to have further
chemotherapy or interventions/invasive procedures.
.
# Leukopenia: Likely chemo related, as last dose was [**3-1**]. ANC
600 so not yet neutropenic and never needed to be on neutropenic
precautions. On 3 18, her WBC began to recover.
.
# Pleurex catheter placed to help with paracentesis/ascites
drainage. SBP treated with ceftriaxone.
Medications on Admission:
# Octreotide Acetate 100 mcg SQ [**Hospital1 **]
# Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H
# Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
# Multivitamin po daily
# Lorazepam 0.5 mg PO Q4H prn nausea
# Loperamide 2 mg po QID prn
# Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H prn
# Nexium 20 mg daily
# Ondansetron 8 mg Q8H prn
# Compazine 10 mg po Q6H prn
# Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily
# NYSTATIN - 100,000 unit/mL Suspension - 4 mL by mouth four
times
daily as needed for thrush swish and swallow
# SUCRALFATE - 1 gram/10 mL Suspension - 10 ml by mouth as
needed
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Spontaneous bacterial peritonitis
Secondary:
Metastatic breast cancer
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
Completed by:[**2179-3-20**]
ICD9 Codes: 5849, 2761, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4407
} | Medical Text: Admission Date: [**2195-7-28**] Discharge Date: [**2195-8-6**]
Date of Birth: [**2130-4-9**] Sex: F
Service: MICU/Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman
with hypertension who developed fevers and rigors on [**7-20**]. She
had been called to go back to the Emergency Room at [**Hospital3 418**] on [**7-23**] with 40% bands and increased white blood
count. Two out of two blood cultures grew out Proteus. She was
treated initially with Levofloxacin and Gentamicin. On the
morning of [**7-24**] she developed rigors, dyspnea, tachycardia and
was also with some mild chest discomfort. Her systolic blood
pressures were in the 60s and heartrate in the 150s. She was
placed on Dopamine and Neo-Synephrine. She had Swan-Ganz
catheter placed via left internal jugular, but the patient had
cardiac arrhythmias and tachycardia so this was changed to a
triple lumen. On [**7-25**], her right internal jugular Swan was
placed with PAD 30/20, PCWP 14 and CVP at 10. Also that day she
became tachycardiac with some dyspnea and choking episodes, and
required intubation. Peak CK was 316, MB 19 on [**7-24**].
Troponins were 8.8. The patient was started on Aspirin, Plavix
and Lovenox on [**7-26**]. She was weaned off of Dopamine, still on
Neo-Synephrine. She developed hemoptysis the same day. Lovenox
and Plavix were stopped. The hypertension persistent and
Dopamine was increased to 7.5 and the Neo-Synephrine to 20. Since
[**7-27**], the pressors were completely weaned and last Dopamine
was given in the ambulance on the way to the [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. The only positive blood culture was
Proteus in two out of two bottles. She also had Escherichia coli
grown out of the urine, sensitive to CTX.
PAST MEDICAL HISTORY: Hypertension, baseline 150/90;
melanoma of left ankle, status post resection; left inguinal
dissection with negative nodes six years ago.
SOCIAL HISTORY: She lives with her husband. She doesn't
smoke.
FAMILY HISTORY: Significant for cancer in her mother.
PHYSICAL EXAMINATION: Physical examination on admission to
[**Hospital6 256**] revealed temperature
37.8, heartrate 82, blood pressure 129/65, peripheral pulses
38/18, CVP 17, CVP 11. Cardiac output 8.3. She was on SIMV
with an FIO2 of 0.5, 12 respirations per minute. Arterial
blood gases on admission was 7.43, 36 and 64. General:
Sedated, obese, elderly white woman in no acute distress.
Head, eyes, ears, nose and throat, sclera clear. Chest:
Coarse breathsounds no crackles. Cardiovascular examination,
tachycardia, normal S1 and S2 with no murmurs. Abdomen,
positive bowel sounds, soft, nontender, no guarding.
Extremities, no lower extremity edema, warm and soft.
Neurological examination, sedated.
LABORATORY DATA: White cell count 8.8, neutrophils 76,
lymphocytes 17. Hematocrit 31.3, platelets 153. PTT 23.1,
INR 1.2, sodium 143, potassium 3.7, chloride 109, carbon
dioxide 25, BUN 16, creatinine 0.5, glucose 123, CK 39,
calcium 8.2, phosphate 3.4, magnesium 1.8. Electrocardiogram
showed normal sinus rhythm, rate 80, normal axis. Chest
x-ray, small lung volumes. Endotracheal tube placement was
confirmed. Echocardiogram was done [**7-24**], positive for
congestive heart failure with ejection fraction 30-35, normal
valves.
HOSPITAL COURSE: Bronchiolar lavage and bronchoscopy were done
on [**7-29**] while the patient was in the MICU for hemoptysis and
adult respiratory distress syndrome. Gram stain was negative.
Cultures were sent. The next day, [**7-30**], abdominal
computerized tomography scan was performed, revealing pleural
effusions bilaterally. The patient was extubated on [**8-3**] and
transferred to the floor on [**8-4**].
Cardiovascular - Her blood pressures were stable and blood
pressure medications adjusted to increase ACE-inhibitor up to 25
mg per day, Lasix was stopped once the patient was on the floor.
She was continued on statin, aspirin and continued to do well
on antihypertensives with blood pressures in the normal range.
Gastrointestinal - The patient was started on soft mechanical
diet which was advanced over the course of the next two days to
house diet. The patient tolerated the diet well. She had soft
bowel movements on Docusate, so the Docusate was stopped.
Infectious disease - The patient was febrile on Levofloxacin
regimen in the Medicine Intensive Care Unit and that was changed
to Ceftriaxone intravenously. Upon transfer to the floor on [**8-4**], the patient was afebrile on Ceftriaxone for 48 hours. The
presumed source of infection was thought to be her lungs.
Prophylaxis - Ms [**Known lastname 42951**] was receiving Protonix 40 mg p.o. once a
day and Heparin for stress ulcer and deep vein thrombosis
prophylaxis. She started ambulation on [**8-4**] and did very well.
DISPOSITION: The patient was discharged to [**Hospital1 21979**] Rehabilitation in [**Location (un) 701**] [**State 350**] on [**8-6**] in
good condition.
DISCHARGE DIAGNOSIS:
1. Urosepsis
2. Non Q wave myocardial infarction
3. Adult respiratory distress syndrome
4. Pneumonia
DISCHARGE MEDICATIONS:
1. Ceftriaxone 1 gm intravenously q. 24 hours for six days
2. Tapazole 40 mg intravenously q. 24 hours
3. Aspirin 81 mg p.o. once a day
4. Nystatin oral suspension 5 mg p.o. q.i.d. as needed for
thrush
5. Albuterol sulfate/epitropion 1 to 2 puffs every 6 hours
and also nebulizer every 6 hours as needed
6. Atorvastatin 10 mg p.o. once a day
7. Captopril 25 mg p.o. three times a day, to be held for
systolic blood pressures less than 100 and diastolic blood
pressures less than 60
8. Metoprolol 75 mg p.o. b.i.d., hold for heartrate less
than 55 and systolic blood pressure less than 90
DISCHARGE CONDITION: She was transferred in house bed with
physical therapy goals to return to baseline and good
rehabilitation potential.
DISCHARGE INSTRUCTIONS: The patient is to follow with her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient is to
call him to schedule her own appointment on discharge from
rehabilitation.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern4) 26613**]
MEDQUIST36
D: [**2195-8-6**] 09:48
T: [**2195-8-6**] 10:07
JOB#: [**Job Number 42952**]
ICD9 Codes: 486, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4408
} | Medical Text: Admission Date: [**2108-1-31**] Discharge Date: [**2108-2-13**]
Date of Birth: [**2029-7-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Peanut
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 78 year old man who fell from standing. Per EMS
([**Hospital1 **] Paramedics) he experienced a fall outside of a place of
business (bar), with +LOC, lac to back of head and large
laceration to L side of head, and +ETOH BAL 57. Pt was intubated
and sedated. Upon assessment, no family was available and
patient
was EU Critical [**Doctor First Name 4468**].
Past Medical History:
HTN, stable angina (with rare NTG use), METS > 4 (limited
ability to climb stairs due to OA, not cardiac/respiratory
related), hyperlipidemia, OSA on home CPAP, h/o prostate CA
treated w/ radiation in '[**93**], h/o diverticulitis, OA, spinal
stenosis for which he takes intrathecal injections every 3
months, last being 4 weeks back.
PSH: epigastric hernia repair '[**57**], Moh's for SCC/BCC
Social History:
Lives with his wife and son. Retired from work. Denies
substance abuse
Family History:
Has a twin brother who had prostrate cancer. Mother had breast
cancer in her 90s. Sister had nephrectomy for a renal tumor
Physical Exam:
On Admission: Gen: Intubated/Sedated
Neuro:
No EO to voice or noxious, Pupils are equal and reactive 3-2mm,
+
corneals bilaterally, no blink to threat, BUE localize briskly
to
noxious, BLE withdraw to noxious and move spontaneously. No
commands.
On Discharge:
Gen: Pleasant, cooperative
CV: RR, s1 and S2 normla
Pulm: CTAB
Gi: soft, NT, obese, + BS
Extr: no c/c/e
Muscl: mild R knee effuission
Neuro: AAOx2, follows commands, strength 4+ throughout, Moving
all extremities, reflex 2+ throughout, left facial droop
Pertinent Results:
CT HEAD W/O CONTRAST [**2108-1-31**]
1. Subarachnoid hemorrhage in the basal cisterns, along the left
temporal
lobe, and along the frontal lobes, including in the
interhemispheric fissure. Adjacent subdural hemorrhage along the
left tentorium, and possibly also in the interhemispheric
fissure and along the left temporal lobe.
2. Possible bifrontal hemorragic contusions.
3. Left frontal scalp laceration without evidence of a fracture.
CT ABD & PELVIS WITH CONTRAST [**2108-1-31**]
1. No evidence of traumatic injury to the thorax, abdomen, and
pelvis.
2. Mild subcutaneous soft tissue hematoma overlying the left
greater
trochanter without evidence of fracture.
3. Chronic moderate-to-severe degenerative changes and L4 on L5
anterolisthesis causing moderate narrowing of the spinal canal.
4. Diverticulosis without diverticulitis.
CT HEAD W/O CONTRAST [**2108-2-1**]
1. No significant short-interval changes, with persistent small
focal
hemorrhagic contusions, predominantly in the left frontal lobe,
trace
bilateral subarachnoid hemorrhage and tiny parafalcine subdural
hematoma.
Interval decrease of conspicuity of the left tentorial and left
temporal
subdural hematomas.
2. No developing hydrocephalus. No new foci of intracranial
hemorrhage.
Follow up as clinically indicated.
cxr [**2108-2-4**]
IMPRESSION: AP chest compared to [**1-31**] through 4:
Pulmonary edema has almost resolved since [**2-3**]. Lungs are
grossly clear. Heart size normal. Left subclavian line ends in
the SVC. ET tube in standard placement. Feeding tube passes into
the stomach and out of view. No pneumothorax.
CTA [**2108-2-4**]
IMPRESSION:
1. No evidence of central pulmonary embolism within limitation
of suboptimal bolus. No acute aortic injury.
2. Bibasilar opacifications likely represent atelectasis, left
greater than right. However, underlying infectious process,
especially on the left cannot be completely excluded and should
be considered in the correct clinical setting.
3. Ground-glass opacities predominantly in the apical segment of
the right
lobe and also within the left lobe are again noted, unchanged
from [**2108-1-31**] and may represent edema, hemorrhage, or
infection.
CXR [**2108-2-5**]
FINDINGS: In comparison with the earlier study of this date, the
right
subclavian catheter has been redirected so that the tip lies in
the
mid-to-distal portion of the SVC. Otherwise little change.
[**2108-2-6**] ECHO
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18435**]Portable TTE
(Complete) Done [**2108-2-6**] at 3:46:36 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
YOUNG, [**Doctor First Name **]
[**Last Name (LF) **], [**First Name3 (LF) **] J.
[**Hospital1 18**] - Division of Neurosurger
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2029-7-20**]
Age (years): 78 M Hgt (in): 72
BP (mm Hg): 142/61 Wgt (lb): 260
HR (bpm): 77 BSA (m2): 2.38 m2
Indication: Endocarditis. Staph bacteremia.
ICD-9 Codes: 424.90, 424.1, 424.0
Test Information
Date/Time: [**2108-2-6**] at 15:46 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**]
[**Last Name (un) 16813**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West
Inpatient Floor
Contrast: None Tech Quality: Suboptimal
Tape #: 2011W000-0:00 Machine: Vivid q-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Stroke Volume: 88 ml/beat
Left Ventricle - Cardiac Output: 6.77 L/min
Left Ventricle - Cardiac Index: 2.85 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - LVOT VTI: 28
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.73
Mitral Valve - E Wave deceleration time: 235 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Estimated cardiac index is normal (>=2.5L/min/m2). No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
Technically suboptimal study.
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified.
CLINICAL IMPLICATIONS:
Based on [**2103**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-2-6**] 17:20
CXR [**2108-2-6**]
Comparison with the study of [**2-5**], the intestinal tubes have been
removed. There is some increasing prominence of the vascular
structures,
consistent with increasing pulmonary venous pressure. Areas of
opacification at the bases may merely reflect some atelectasis
and vascular structures, though in the appropriate clinical
setting the possibility of supervening pneumonia would have to
be considered, especially at the right.
[**2-12**] Lumbar MRI
1. Transitional anatomy at the lumbosacral junction with
numbering
convention, as detailed above.
2. No finding to specifically suggest discitis, vertebral
osteomyelitis or
epidural abscess/phlegmon in the lumbar spine. However, there is
abnormal
enhancing soft tissue in the caudal aspect of the left neural
foramen at the L4-5 level, adjacent to the exiting left L4 nerve
root, which may relate to the annular tear of the adjacent disc
or to the patient's history of recent "spinal injections"; this
finding should be closely correlated with more detailed
information regarding those procedures.
3. No pathologic focus of radicular or leptomeningeal
enhancement.
4. Severe multilevel, multifactorial degenerative disease,
superimposed on
congenitally abnormal spinal canal geometry, with resultant
severe spinal
canal stenosis at the L4-5 level and multilevel neural foraminal
stenoses, as detailed above.
5. Grossly unremarkable appearance to the imaged paraspinal soft
tissues with no finding to specifically suggest renal, perirenal
or psoas muscle abscess.
LENIs [**2-13**] - negative for DVT
Brief Hospital Course:
This is a 78 year old man s/p unwitnessed fall with + LOC who
was intubated and sedated and sent to ED. On head CT patient was
found to have SAH, SDH, and bifrontal contusions. He was cleared
by trauma for other injuries and transferred to TSICU for Q1H
neuro exams. He remained intubated, but was able to open eye to
voice, localize briskly with BUE, and spontaneous movement in
BLE. Overnight, patient was extubated and on [**2-3**], he was alert
to himself, following simple commands, moving all extremities
antigravity and to commands. His cervical spine was cleared.
Whilst in the ICU he had an epsiode of hypotension and got
re-intubated. His work up yeilded Gm + cocci bacteremia. CTA of
the chast was negative for PE. ECHO was negative for vegitation.
He was started on abx and all of his lines were changed over.
An ID consult was called.
He was extubated a day later and has been doing well. He was
transferred to the stepdown.
He had a speach and swallow evaluation on [**2-6**] which showed signs
of aspiration on thin liquids and mild oral residue with regular
solids. They recommend a PO diet of
nectar-thick liquids and soft solids with 1:1 supervision. They
continued to follow.
A TEE was attempted on [**2-9**], the patient was unable to tolerate
the study w/o additional sedation, hence the study was deffered
and can be performed on an outpaient basis. Recs were left in
paperwork. Patient's diet was advanced and he was transferred to
the floor from the SDU on [**2-10**].
On [**2-11**] the patient remained stable. ID recommended checking
ESR,CRP,WBC since pt had been low grade temps since admission.
They also recommended an MRI L-spine since he had an ESI 2 weeks
prior to initial presentation. He worked with PT and OT.
On [**2-12**] ID recommend a lumbar MRI after it was discovered that
he had a previous steroid injection. MRI shoed no evidence of
discitis or osteomyelitis. Addition, ID recommend a ortho
consult to evaluate right knee effusion as a source of
bacteremia. Ortho evaluated pt on [**2-13**] and recommended that R
knee was not likely to be septic. No further evaluation needed.
On [**2-13**] PICC line was pulled out by patient. PICC line was
reinserted on [**2-13**] with a CXR confirming placement. Now DOD, he
is set for d/c to rehab in stable condition. He will continue
Nafcillin for 4 weeks. He will f/u with ID with Transesophageal
echocardiogram and Dr. [**First Name (STitle) **] in [**2-3**]-6 weeks.
Medications on Admission:
[**Last Name (un) 5487**]
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for PARAPHYMOSIS.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for discomfort.
7. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for discomfort.
8. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. ziprasidone mesylate 20 mg Recon Soln Sig: One (1) Recon Soln
Intramuscular Q6H (every 6 hours) as needed for Agitation.
10. hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 140.
11. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours).
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. 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.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. Outpatient Lab Work
ESR, CRP, CBC with diff qweekly - Monday to be faxed to [**Hospital **]
clinic at [**Hospital1 18**] [**Telephone/Fax (1) 1419**]. Attention: Dr. [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) 4427**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
BIFRONTAL CONTUSIONS
ACUTE DELIRIUM
SUBARACHNOID HEMORRHAGE
SUBDURAL HEMATOMA
FACIAL LACERATION
BACTEREMIA
RESPIRATORY FAILURE
R knee pain with mod effusion
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:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2108-2-13**]
ICD9 Codes: 5185, 7907, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4409
} | Medical Text: Admission Date: [**2197-2-7**] Discharge Date: [**2197-2-9**]
Date of Birth: [**2144-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
Ms [**Known lastname **] is a 52 yo female with history of Hep C cirrhosis and
known varices with previous epsiodes of upper GI bleeding who
came to the ED with 2 episodes of hematemsis over the past 3
days.
She states she has been having a couple wine spritzers a night
over the holidays. She ate Mexican food on Saturday and became
nauseous and vomited food mixed with bright red blood (about a
[**Female First Name (un) **] cup worth). She then ate the Mexican food again yesterday
and became nauseous and threw up food with a smaller amount of
bright red blood. She denies any blood in her stool or black
stool, although she does state her stool has looked darker over
the past few days. She had one episode of diarrhea after the
inital vomiting episode.
Of note, she had an admission in [**5-14**] with a similar
presentation during which she had banding of esophageal varices.
She has no followed up with hepatology in the intervening time.
In the ED, her initial VS were : T 98.4 HR 104 BP 128/70 RR
18 Sat 100% on RA. On rectal exam she had dark, guaiac
positive stool. NG lavage was positive for about 20 cc of
bright red blood which cleared quickly. Hct was 23.7 (from high
20's). She was given 80 mg IV protonix, started on an
octreotide gtt, and given 1 gm IV ceftriaxone. Blood was
ordered, but not given in the ED. She had 18 and 20-gauge IVs
placed. GI was consulted who requested ICU admission for EGD
this afternoon.
ROS: The patient states she has had a cough for the last month.
She denies fevers, chills, HA, shortness of breath, chest pain,
abdominal pain, edema, or other symptoms.
Past Medical History:
- Hepatitis C; diagnosed 2 years prior (per patient, no h/o IVDU
but may have contracted through transfusion of sexual
transmission with IVDU in past), no current treatment,
complicated by varices s/p banding in [**5-14**]
- h/o PUD and antral erosions in past s/p H. pylori treatment in
[**9-/2194**]
- Iron deficiency anemia (recent baseline around 27) undergoing
on IV Fe and occasional blood transfusions
- GERD
- Hypertension
Social History:
She lives alone, does marketing. She has been drinking [**2-5**] wine
spritzers per day over the holidays. Denies tobacco or IVDA.
Family History:
Her mother had GI bleeding of unknown source and her sisters all
have iron-deficiency anemia.
Physical Exam:
GEN: Middle-aged female laying in bed in NAD. Alert and
appropriate.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy
RESP: Breathing comfortably, CTAB.
CV: RRR, no MRG
ABD: +BS, soft NTND, no hepatosplenomegaly.
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: No asterixis. Grossly nonfocal.
Pertinent Results:
Admission labs:
Na 135 K 3.7 Cl 102 Bicarb 21 BUN 13 Cr 0.7 Glu 135
.
WBC 6.7 Hct 23.7 Plt 242
.
N 71.1% L 21.1% M 6.3%
.
PT 19.5 PTT 24.8 INR 1.8
Imaging:
CXR: read pending ***
EGD report pending ***
Brief Hospital Course:
Ms [**Known lastname **] is a 52 yo female with Hep C cirrhosis complicated by
varices and chronic anemia who presented to the ED with two
episodes of hematemesis.
# Hematemesis: The patient has a history of upper GI bleeds
from esophageal varices and gastric erosions. EGD upon
admission showed a medium sized varix in distal esophagus with
recent evidence of bleeding which was banded. The octreotide gtt
started in the ED was stopped. Treatment with a [**Hospital1 **] PPI was
continued. Sucralfate 1 gram tid was started and will be
continued for 7 days after discharge. She was started on
nadolol the day of discharge. She has a repeat EGD scheduled
for 2 weeks.
# Acute on chronic anemia: Patient has a history of iron
deficiency anemia and receives IV iron and occasional blood
transfusions. Acute decline in her hct is likely from her GI
bleed. Last received IV iron in the beginning of [**Month (only) 1096**]. She
was transfused 1 unit PRBC with stabilization of hct. On
[**2196-2-9**], transfused 2 more units prior to discharge to the floor.
HCT was stable on the floor and she had no repeat melena or
hematochezia.
# Hep C cirrhosis: Patient has a history of untreated hepatitis
C cirrhosis. Her nadolol was held initially due to her bleed,
but restarted before discharge. She was treated with ceftrixone
for SBP prophylaxis in the setting of a GI bleed. She was
transitioned to ciprofloxacin upon discharge. She has
outpatient gastroenterology follow up.
# Alcohol use: The patient continues to use alcohol. Social
work was consulted and it was recommended that she abstain from
further alcohol use. She was monitored on a CIWA scale for
withdrawal without any effect. She will see social work as an
outpatient.
Comm: [**Name (NI) **] [**Name (NI) **], sister ([**Telephone/Fax (1) 93074**]
Code: DNR/DNI (but reversed for the procedure)
Medications on Admission:
(confirmed with the patient)
1. Nadolol 40 mg po daily
2. Omeprazole 40 mg PO daily.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4
days.
Disp:*8 Tablet(s)* Refills:*0*
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO three
times a day.
Disp:*1 bottle (420 mL)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal variceal bleeding
Acute blood loss anemia
Hepatitis C cirrhosis
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 bleeding varices,
abnormal blood vessels in the esophagus from liver disease.
These were treated with banding during your endoscopy. You were
transfused 3 units of blood. You will need to have another
endoscopy scheduled for [**2197-2-21**] (see below).
It is strongly recommended that you do not drink any alcohol, as
this may seriously worsen your liver disease.
The following medication changes were recommended:
1) Nadolol was CHANGED to 20 mg TWICE daily.
2) Omeprazole was CHANGED to pantoprazole 40 mg TWICE daily.
3) Start ciprofloxacin 500 mg TWICE daily for 4 days.
4) Start sucralfate 1 gram THREE times daily for 7 days.
Followup Instructions:
Department: ENDO SUITES
When: TUESDAY [**2197-2-21**] at 2:30 PM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2197-2-21**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Please call the office of Dr. [**First Name (STitle) 26390**] at [**Telephone/Fax (1) 2296**] for an
appointment 1 month after discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2197-2-9**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4410
} | Medical Text: Admission Date: [**2114-12-19**] Discharge Date: [**2115-1-1**]
Date of Birth: [**2043-12-9**] Sex: F
Service: GEN SURGERY
HISTORY OF PRESENT ILLNESS: Patient is presenting with a
sternal wound infection. She had been slowly improving from
a coronary artery bypass graft on [**2114-10-25**] and was
being seen on a routine postoperative wound checks with no
symptomatology. She had no fever, no chills and no redness.
This morning, when she awoke on [**12-19**], she noticed a
large amount of drainage, which increased from the upper part
of her incision on her sternum, and on exam it was open half
a cm draining a copious amount of purulent pus.
PAST MEDICAL HISTORY:
1. Significant for a coronary artery bypass graft times two
on [**2114-10-25**], was off pump.
2. Right carotid endarterectomy on [**2114-10-22**] with Dr.
[**Last Name (STitle) 1391**]. Atrial fibrillation, postoperative delirium.
3. Chronic back pain.
4. Non Q wave myocardial infarction.
5. Hypercholesterolemia.
6. Migraines headaches.
7. PVT.
8. Hypertension.
9. Previous left carotid endarterectomy.
MEDICATIONS: She takes Lopressor 100 mg t.i.d. at home,
Plavix 75 mg once a day, Lisinopril 20 b.i.d. and amiodarone
200 mg once a day, Zosyn 75 once a day, Devoprolax 125
b.i.d., aspirin 81 once a day, Norvasc 10 once a day, Colace
100 b.i.d., Dolculax as needed, oxycodone as needed, Percocet
as needed and Tylenol as needed.
HOSPITAL COURSE: She was started on wide spectrum
antibiotics and sent to the Operating Room the following day
where she underwent a sternal debridement and was transferred
to the Intensive Care Unit with an open chest and was
paralyzed and sedated, where she remained thus until [**10-23**] when Plastic Surgery took her to the Operating Room where
she had a right pectoral muscle/rectus flap procedure done.
Postoperatively, she was then transferred to the Intensive
Care Unit where she was slowly weaned off her sedation and
weaned off of paralytics, weaned off vent requirements and
was eventually extubated without incident. At this point,
she was transferred to the floor.
The patient had been started on oxacillin, which the
Operating Room cultures grew back positive for methicillin
sensitive Staphylococcus aureus. She was transferred to the
floor where she continued to receive Physical Therapy and
Plastic Surgery was constantly evaluating her wound.
For her cardiac, however, she had hypotension and her
medications were titrated upwards in regard to this. A PICC
line was then placed on her on [**2114-12-31**] for
long-term antibiotics.
Patient, on physical examination, this morning has clear
heart and lungs. The incision looks clean and dry with
minimal exudate. No evidence of cellulitis, some baseline
redness. VNA and an Infusion Therapy has been set up for her
to receive oxacillin 2 grams intravenous q. 6h for the next
six weeks postoperatively, to end on [**2115-1-31**].
DISCHARGE MEDICATIONS:
1. Colace 100 mg po b.i.d.
2. Iron gluconate 300 mg po q.d.
3. Oxycodone SR 10 mg po q. 12 h.
4. Lopressor 50 mg po t.i.d.
5. Norvasc 10 mg po q.d.
6. Amiodarone 400 mg po q.d.
7. Aspirin 325 mg po q.d.
8. Protonix 40 mg po q.d.
9. Dilaudid 2-4 mg as needed for pain.
DISCHARGE PLAN: The patient understands the discharge plan.
She will go home to follow-up with Dr. [**Last Name (STitle) 5385**], who was the
Plastic Surgeon who did the surgery, in one week. Plastic
Surgery has been made aware of this plan and discharge. She
will also follow-up with Dr. [**Last Name (STitle) 1537**], as well as the nurse
practitioning staff on Cardiac Surgery. The patient, upon
discharge, has been afebrile with a white blood cell count of
less than 5, doing well, with a stable hematocrit.
She still has ongoing active issues and will follow-up with
her primary care physician as well for optimization of her
cardiac medications.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2115-1-1**] 12:04
T: [**2115-1-1**] 14:54
JOB#: [**Job Number 34718**]
ICD9 Codes: 7907, 412, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4411
} | Medical Text: Admission Date: [**2159-7-5**] Discharge Date: [**2159-7-10**]
Date of Birth: [**2112-11-21**] Sex: M
Service: [**Hospital1 **] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with
history of ethanol abuse, HIV positive presenting with
hypotension with systolic blood pressures in the 60s
associated with light-headedness/dizziness. Also reports
vomiting, diarrhea, and decreased p.o. for several days.
Last drink on AM of admission. Was drinking half a gallon of
vodka per day for one week prior to admission.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus, long term
nonprogressor.
2. Hypertension.
3. History of rheumatic fever.
4. Status post cholecystectomy.
PHYSICAL EXAMINATION: Pertinent positive was that the
patient came in and he was being followed with the CIWA
protocol and had CIWA scores in the high teens and, given the
protocol, was given Valium and followed closely.
LABORATORY DATA: On admission he was getting 20 [**Hospital1 **] of
Valium with 7.5 mg q two hours per CIWA protocol if his CIWA
was over 10, and he had an increased standing dose to 30 if
it got worse, basically, if the regimen was not making him
stable. Also on admission he also had blood cultures which
were positive for gram positive cocci times three out of four
bottles, had UA and chest x-ray, which were both negative.
He also had sodium of 115 on admission which has since gotten
fixed and is since up to 132.
He also was in acute renal failure, a creatinine of 2.4,
which was improved with fluids since.
He also had a macrocytic anemic picture with MCVs of over
100. This is most likely secondary to ethanol marrow
toxicity, which is improving as well.
HOSPITAL COURSE: Patient is since being admitted on [**7-5**] to
[**Hospital1 139**]. Patient was being followed on CIWA protocol for his
ethanol withdrawal.
1. Ethanol withdrawal. The Diazepam was titrated. He was
initially on 20 mg [**Hospital1 **] with also 7.5 mg q two hours per CIWA
protocol. He was kept on that protocol until [**7-8**], at which
point his CIWA had been under 10 and it was decided to
decrease his scheduled dose and, for the next day, which was
[**7-9**]. So, for [**7-9**] his scheduled dose was decreased to 10,
but then he required an extra 7.5 because of being jittery,
followed them for the rest of the day, and his CIWA scores
were under 8 for the rest of the day, at which point decision
was made to discontinue his Diazepam and keep him on the CIWA
prn but discontinue the scheduled Diazepam and instead put
him back on his outpatient regimen of Klonopin 0.5 mg tid.
Patient tolerated that well and, today, [**7-10**], patient has
been on his Klonopin. His jitteriness and tremor have
decreased quite a bit, although still present.
2. ID. There were blood cultures were positive and they
showed coagulase negative staph. This was most likely
secondary to skin contaminant. Patient was started on
Vancomycin through PICC line, and another culture was drawn
on [**7-6**], which has been negative to date. Since it has been
negative four days after, decision was made to stop
Vancomycin and DC the PICC line on discharge, and patient has
been afebrile, also.
3. His hyponatremia on admission was 115. It was fixed with
normal saline times five liters so far, and it is within
normal limits now.
4. His renal failure. He had acute renal failure which had
a creatinine of 2.4 which is now, on discharge, .9 with
fluids only.
5. His macrocytic anemia persists most likely secondary to
ethanol marrow toxicity. Patient received folate and
thiamine while in hospital.
6. Patient's discharge condition was improved and stable on
[**7-10**].
DISCHARGE STATUS: Patient was discharged to home and to
follow up with Rehab as scheduled per primary care physician
after going home. Rehab Center has contact[**Name (NI) **] patient, and
patient to follow up with Rehab accordingly.
FINAL DIAGNOSIS: Alcohol withdrawal.
DISCHARGE RECOMMENDATIONS:
1. Patient to follow with primary care physician in one to
two weeks. Primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) 4702**].
2. Patient is to participate in rehab post detox after
discharge from hospital. Patient knows the date, time, and
location of the rehab.
3. Patient to seek medical care if symptoms return or new
symptoms arise.
4. No major surgical or invasive surgeries done.
DISCHARGE CONDITION: Stable and improved.
DISCHARGE MEDICATIONS:
1. Multivitamins, one a day.
2. Nicotine 21 mg patch, one a day.
3. Propranolol 20 mg [**Hospital1 **].
4. Venlafaxine 75 mg [**Hospital1 **].
5. Tylenol prn for pain.
6. Klonopin 0.5 mg tid.
Patient to follow up with medication regimen with primary
care physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**]
Dictated By:[**Last Name (STitle) 33907**]
MEDQUIST36
D: [**2159-7-10**] 14:42
T: [**2159-7-19**] 22:47
JOB#: [**Job Number 33908**]
ICD9 Codes: 4589, 2765, 5849, 2761, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4412
} | Medical Text: Admission Date: [**2145-8-9**] Discharge Date: [**2145-8-16**]
Date of Birth: [**2087-8-18**] Sex: M
Service: Medicine - [**Location (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
quadriplegic male who was recently discharged from [**Hospital6 1760**] with the diagnosis of
pseudomonal infection of PICC line who now returns back with
magnetic resonance imaging scan findings consistent with an
abscess at the T4-5 level. This is Mr. [**Known lastname 93873**] third
admission over one month period. He was first admitted first
on [**2145-7-4**] with a chief complaint of fevers and chills
and symptoms of urinary tract infections that persisted
despite treatment with Ciprofloxacin. He was found to have
Methicillin-sensitive Staphylococcus aureus bacteremia and
T4, T5, T8 and T9 diskitis. The patient was subsequently
treated with ultrasound and sent home with a PICC line. He
rejoined on [**8-2**] with similar symptoms and was found to
have infection of the PICC line and urinary tract infection.
Both PICC line catheter tip and urinary cultures grew
Pseudomonas which was treated with Cefepime. At that time
Oxacillin was discontinued. Prior to his discharge, during
this admission, he received magnetic resonance imaging scan
of his spine. After discharge results of the magnetic
resonance imaging scan became available and the patient was
readmitted to the hospital on [**8-9**], with magnetic
resonance imaging scan findings consistent with T4 and T5,
epidural abscess. The patient was contact[**Name (NI) **] prior to this
admission by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and
after consultation with Dr. [**Last Name (STitle) 1338**] from Neurosurgery he was
admitted to [**Location (un) **] Medicine for the workup of possible
abscess.
PAST MEDICAL HISTORY: Past medical history includes 1.
Quadriplegic times 30 years secondary to a water skiing
accident; 2. Neurogenic bladder; 3. Anxiety; 4.
Osteoporosis; 5. History of pneumonias; 6. Anemia; 7.
Hemorrhoids.
MEDICATIONS ON ADMISSION: Cefepime 1 gm q. 12 hours;
Buspirone 30 mg p.o. once a day; Loxitane, Ditropan,
Dulcolax, Colace, Lomotil, Ativan.
ALLERGIES: The patient has allergy to Bactrim, Erythromycin
and Zoloft.
SOCIAL HISTORY: Quit smoking 30 years ago. He is married,
former accountant.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: Temperature 99.3, heartrate 97, blood
pressure 107/73, respirations 20. Oxygen saturation is 97%
on room air. General, in no acute distress, oriented times
three. Head, eyes, ears, nose and throat, extraocular
movements intact. Pupils equal, round, and reactive to light
and accommodation bilaterally. Oropharynx clear. No
jugulovenous distension noted. Cardiovascular examination,
regular rhythm and rate, no murmurs. Normal S1 and S2, point
of maximal impulse not displaced. Pulmonary, clear to
auscultation bilaterally. Abdomen, firm, nontender,
nondistended, positive bowel sounds. Extremities, no edema.
2+ Pulses in all four extremities.
LABORATORY DATA: Sodium 129, potassium 3.7, chloride 93,
bicarbonate 23, BUN 14, creatinine 0.4, glucose 99. White
blood cell count 10.6 with 88.6 neutrophils and 6.2
lymphocytes. Hematocrit 31.3 and platelets 395. Chest x-ray
showed increased left lower lobe opacity with air
bronchograms concerning for worsening pneumonia. It also
showed small left pleural effusion.
HOSPITAL COURSE: Mr. [**Known lastname 3803**] was admitted to the floor for
further workup of possible epidural abscess at the T4-5
level. He received computerized tomography scan guided
biopsy the next day after admission. The biopsy was
significant for large amounts of pus-looking fluid, however,
gram stain was negative and cultures were pending at the time
of this dictation. He Cefepime was discontinued and the
patient was started on Levofloxacin and Oxacillin to cover
for possible Staphylococcal infection of his spine.
Secondary to spinal cord damage, the patient could not feel
pain, however, continued to sweat profusely which according
to the patient is the only manifestation of his pain
symptoms. He was treated for sweats with pain medications,
specifically Percocet and Demerol were given on a prn basis
with good response. On [**8-13**], the debridement of T4, T5
spine was done by Dr. [**Last Name (STitle) 1338**]. Transpedicular decompression
of T4, T5 segments was also performed at this time with
minimal blood loss and no complications. There was an
extensive depth infected appearing tissue in the epidural
space of T4 and 5 disc. The specimens were taken during the
surgery and sent to Pathology and all specimen results were
pending at the time of this dictation. There was no gross
pus found in surgery. The drain was placed on the left in
the T4-T5 disc space. The patient returned to the floor on
[**8-13**] and continued to have sweats, but was afebrile and
otherwise reported feeling better. His hematocrits went down
to 26.6 after the surgery, however, it went back up to 29.6
on [**8-15**]. Therefore no blood transfusion was given. At
the time of this dictation, the patient was anticipated to be
discharged on [**8-16**] to home on Oxacillin and Levofloxacin.
The plan for antibiotic coverage was to continue Levofloxacin
for 14 days after discharge and Oxacillin for at least six
more weeks. Reimaging of the spine with magnetic resonance
imaging scan was also planned in about two weeks after
discharge.
DISCHARGE MEDICATIONS: He was anticipated to go home on the
following medications-
1. Oxycodone 5 mg p.o. q. 4-6 hours as needed for seats
2. Oxacillin 2 gm intravenously every 4 hours
3. Levofloxacin 500 mg p.o. q. day
4. Cefadyl 10 mg p.r. q.d. as needed
5. Docusate sodium 100 mg p.o. b.i.d. prn
6. Lorazepam 0.5 mg p.o. h.s. prn
7. Oxybutynin 5 mg p.o. b.i.d.
8. Loxitane 20 mg p.o. b.i.d.
9. Buspirone 10 mg p.o. t.i.d.
10. Metoprolol 25 mg p.o. b.i.d.
11. Simethicone 80 mg p.o. q.i.d. prn
12. Diphenoxylate/Atropine 2 tablets p.o. q. 6 prn
DISCHARGE INSTRUCTIONS: He was anticipated to be discharged
home on a regular diet. Follow up to be arranged by the
patient with Dr. [**Last Name (STitle) **] and Infectious Disease.
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**Name8 (MD) 93874**]
MEDQUIST36
D: [**2145-8-15**] 10:41
T: [**2145-8-15**] 15:14
JOB#: [**Job Number 93875**]
ICD9 Codes: 5119, 5990, 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4413
} | Medical Text: Admission Date: [**2177-5-28**] Discharge Date: [**2177-6-25**]
Date of Birth: [**2121-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Plasmpheresis
Ultrafiltration
Intubation
Central Line placement
History of Present Illness:
This is a 56 year old male with a history of Osteomylitis of the
right foot (recent admit at [**Hospital1 **]), CAD (s/p MI and stend in [**2161**],
and [**2174**], ?sternotomy?), CHF (?diastolic v. right sided from
PAH/pulm stenosis), moderate pulm artery HTN based on echo,
pulmonic stenosis, A-fib who was recently diagnosed with CML,
not started on treatment yet, who was transferred to [**Hospital 18**]
medical floor on evening of [**5-28**] for further managment of
osteomylitis.
.
On the medical floor a history was moaning and a history and ROS
was unable to be attained. He was noted to be volume overloaded
and given his respiratory distress he was given lasix. His
respiratory status continued to decline. An ABG was 7.28/45/65.
He was transferred to the unit for respiratory distress.
.
Review of systems:
Unable to attain secondary to patient somnolence
Past Medical History:
CAD s/p MI with stent in [**2161**]
CHF
Atrial fibrillation on Coumadin
Diabetes Type 2 on Insulin
Hypertension
Hyperlipidemia
CML (new diagnosis)
Peripheral [**Year (4 digits) 1106**] disease s/p R SFA stent angioplasty and L
SFA stent placement
Lower extremity cellulitis with surgical debridement/VAC
Brain Tumor s/p craniectomy
Gastroporesis
Neuropathy
Congenital Pulmonic Stenosis
Chronic indwelling foley.
Depression diagnosed at [**Hospital3 **], refused SSRIs
Social History:
Nonsmoker, no alcohol consumption
Family History:
No history of renal failure or disease. Mother with ? [**Name2 (NI) **]
dyscrasia
Heart disease in unspecificed family members.
Physical Exam:
General: Oriented to self. In moderate respiratory distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to assess JVP.
Lungs: Rhales b/l at bases.
CV: Tachy, S1+, S2+, +systplic murmur, III/VI.
Abdomen: Diffusely tender. +gaurding. No rebound. Non-distended.
GU: foley
Ext: Cold, right foot dressed.
Pertinent Results:
CYTOGENETICS:
FISH evaluation for a BCR-ABL rearrangement was performed
on nuclei with the Vysis LSI BCR/ABL Dual Color, Dual
Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for BCR at
22q11.2 and ABL at 9q34, and is interpreted as ABNORMAL.
Rearrangement was observed in 92/100 nuclei, which exceeds
the normal range (up to 1% dual rearrangement) for this
probe in our laboratory. A BCR-ABL rearrangement is found
in most cases of CML, and in a subset of cases of ALL and AML.
.
BONE MARROW BIOPSY:
FISH evaluation for a BCR-ABL rearrangement was performed
on nuclei with the Vysis LSI BCR/ABL Dual Color, Dual
Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for BCR at
22q11.2 and ABL at 9q34, and is interpreted as ABNORMAL.
Rearrangement was observed in 95/100 nuclei, which exceeds
the normal range (up to 1% dual rearrangement) for this
probe in our laboratory. A BCR-ABL rearrangement is found
in most cases of CML, and in a subset of cases of ALL and AML.
.
FOOT X-RAY:
1. Evidence of cortical destruction and loss at the fifth
metatarsal head and neck on the right, either due to
osteomyelitis or prior debridement.
2. Faint lucency through navicular on the right of uncertain
significance. Correlate with focal symptoms.
3. Some loss of morphology of the right calcaneus is seen, but
no frank
cortical destruction.
4. Probable left fifth metatarsal base fracture.
5. Area of relative lucency and cortical ill definition at the
medial aspect of the left fifth metatarsal head may represent an
area of cortical
destruction due to osteomyelitis, although the appearance is
nonspecific.
.
PATHOLOGY BONE BIOPSY 5th METATARSAL HEAD:
Bone, right fifth metatarsal head (A):Regenerative bone and
fibrous tissue with focal acute inflammation, consistent with
ulcer bed; no acute osteomyelitis seen. Small juxta-trabecular
lymphoid aggregate.
.
CT ABDOMEN/PELVIS/CHEST ([**2177-5-30**]):
1. Large left and small right pleural effusions with question of
loculation superiorly, as before, though this come be from
chronic pleural scar. Interstitial thickening consistent with
mild pulmonary edema.
2. Mild-to-moderate ascites around the liver and tracking into
the pelvis.
Diffuse anasarca, consistent with third spacing.
3. No evidence of acute bowel abnormality. No hemoperitoneum or
pneumoperitoneum to suggest splenic rupture or bowel
perforation.
4. Extensive coronary artery atherosclerotic calcification.
5. Enteric tube sideport situated above GE junction; advance for
standard
positioning.
.
ECHOCARDIOGRAM ([**6-17**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). The anterior septum appears hypokinetic. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. The pulmonic valve leaflets are
thickened. There is moderate pulmonic valve stenosis.
Significant pulmonic regurgitation is seen. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is no pericardial effusion.
IMPRESSION: Compared with the findings of the prior study
(images reviewed) of [**2177-5-30**], no obvious change but the
technically suboptimal nature of both studies precludes
definitive comparison.
.
LABS AT THE TIME
[**2177-6-25**]:
WBC 5.5
HB 8.5
HCT 25.0
PLT 100
Na 138
K 4.0
Cl 99
CO2 30
BUN 35
Creat 2.4
Ca 9.6
Mg 1.6
Phos 2.1
HBsAg Negative
HBsAb Borderline
HBcAb Negative
PPD negative
MRSA swab positive
Brief Hospital Course:
MICU COURSE [**Date range (3) 47033**]
.
56 yo M with PMH of CHF, PVD, recent dx osteomyelitis on
linezolid and irtepenem, newly dx'ed CML, pulmonic stenosis, CAD
and DM was transferred from an OSH for further management of
CML. He was initially admitted to the floor and found to have a
white [**Date range (3) **] cell count of 280,000. He triggered for hypoxia and
delirium several hours after admission and was transfered to the
ICU. He was intubated for hypoxic respiratory failure and
delirium both thought to be [**12-31**] leukostasis.
.
.
# Hypoxic Respiratory Failure: Initially thought to be secondary
to pulmonary leukostasis. Also ulitmately from pulmonary edema
and ventilator associated pneumonia. Was plasmapheresed and
received chemotherapy as below. Also received significant
hydration in setting of uric acid of 14 and systemic
chemotherapy. Became massively fluid overloaded requiring
ultrafiltration intermittently. Spiked fevers and was bronched
which showed LLL PNA. Initially treated with linezolid,
cefepime and cipro which was narrowed to daptomycin and cefepime
to complete treatment for VAP. Stenotrophomonas grew from his
sputum but thought to be a colonizer as was clinially improving
not on bactrim. He had difficulty weaning from the ventilator
so tracheostomy was placed. With initiation of dialysis /
ultrafiltration and aggressive fluid removal he was able to be
weaned to trach mask. He was off the ventilator for > 24 hours
at the time of discharge.
.
# Leukemia: Had been newly diagnosed CML prior to admission.
WBC was 280K. Oncology was consulted on admission and the
patient was treated with Hydrea and Gleevec. He was started on
allopurinol. He underwent plasmapheresis once. Peripheral [**Month/Day (2) **]
was bcr-abl positive. Bone marrow biopsy was not adeuate for
further cytogenetics but was also bcr-abl positive, consistent
with accelerated CML, and he was continued on above treatment.
His white cell count decreased to normal range. In consultation
with the hematology oncology service, gleevac was stopped as
his WBC normalized and his hematocrit and platelet count were
low. Plan would be to restart if platelet counts become >150,000
or if white cell count increases. Gleevec dose would be 100mg
every other day. Allopurinol was stopped. He will follow up
with hematology-oncology.
.
# Acute Renal Failure: The acute on chronic renal insufficiency
was thought to be secondary to uric acid nephropathy. He
underwent ultrafiltration with volume removal. The renal failure
was initially non-oliguric and he was started on diuretics.
However, his urine output trailed off and his creatinine
worsened. He underwent placement of a tunneled line and was
started on alternating hemodialysis and ultrafiltration for
fluid removal. He was started on sevelemer but this was stopped
as his phosphate was low-normal. He should continue to have HD
on tuesday/thursday/saturday. Sevelamer should be restarted if
phosphate level rises. Epogen was started and should be given
with dialysis, 5500 units qHD.
.
# Ventilator acquired Pneumonia: Spiked fever and was bronched
showing LLL PNA. Treated with daptomycin (changed from
linezolid due to concern for marrow suppression), cefepime and
cipro for VAP.
.
# Hypotension: Was intermittently hypotensive requiring pressor
suppor which correlated to need for sedation and pain control as
had siginficant pain.
.
# Fever: Patient developed fever while intubated and was treated
with abx as above. Also treated with micafungin for several
days given he had significnat skin breakdown from anasarca and
concern for fungal infection. This was stopped once bronch
showed LLL PNA thought to be source of fever. HE defervesed
several days after bronchoscopy.
.
# Osteomyelitis: Diagnosed as OSH several days prior to
transfer with culture growing MRSA, VRE, and multiply resistant
Proteus. Initially treated with linezolid and irtepenem which
was changed to meropenem on admission. Podiatry was consulted
and took a bone swab which grew out nothing. Ultimately treated
with daptomycin (changed from linezolid due to concern for
marrow suppression) and cefepime (also covering for VAP in
presence of purulent sputum on bronch) for a total of 6 weeks,
last dose planned for [**2177-7-8**]. CBC, LFTs, CK, BUN/CREA should be
checked weekly and sent to infectious disease.
.
#Ventricular tachycardia: He developed asymptomatic
non-sustained ventricular tachycardia. He was evaluated by the
electrophysiology service. This was most likely due to ketamine,
which he was on for pain control. The ketamine was stopped and
the ectopy resolved. He was started on metoprolol for
suppression of ectopy.
.
# Thrombocytopenia: Developed in setting of chemotherapy and
systemic illness. Not thought to be HITT. Required
transfusions for <50 given GIB (see below) and procedures.
Linezolid changed to Daptomycin given concern for bone marrow
suppression.
.
# Anemia: Initially thought to be secondary to chronic illness,
chemotherapy. Developed acute [**Month/Day/Year **] loss anemia with melanotic
stool and hct drop to 19. GI scoped and saw esophagitis and
gastritis. Required transfusions on several occasions for
hct<21. He was continued on a PPI. HCT on discharge was 25.0.
.
# Acute Pain: Was in [**9-7**] pain on admission to ICU likely from
bony pain from his leukemia. Required significant amounts of
fenanyl while intubated to keep pain at [**2177-4-3**]. Used dilaudid
iv and ultimately a ketamine drip to control pain. He developed
ventricular tachycardia on ketamine so this was stopped. The
fentanyl was weaned down and he was transitioned to a fentanyl
patch with dilaudid PO PRN, which kept his pain at 5-7 which he
deamed tolerable.
.
#Atrial fibrillation: He has a history of atrial fibrillation on
coumadin. This was held in the setting of his hematocrit drop.
Coumadin was restarted at a dose of 5mg per day on [**2177-6-25**]. He
should have INR checked daily until therapeutic. HCT should be
monitored in the setting of anticoagulation given his GI Bleed.
Once INR is 2.0-3.0, please d/c the Heparin SC.
.
# Chronic Diastolic Heart Failure: Initial concern for
component of cardiogenic shock given hypotension and renal
failure. Echo showed normal EF though had poor windows.
Developed pulmonary edema in setting of massive fulid hydration
with chemo. Required lasix gtt, metolozone and ultimately
ultrafiltration.
.
# Rash: Pt with new erythematous, scaling rash on forehead. He
was started on a steroid cream with significant improvement.
.
# Ileus: Imaging showed no SBO. Treated with Reglan which was
then discontinued.
.
# Code: Full
.
FOLLOW-UP AT REHAB:
1. Hemodialysis on Tuesday/Thursday/Saturday, epo to be given
with HD
2. Start Sevelamer if Phosphate rises
3. When platelets > 150, or if WBC rise restart Gleevec at 100mg
every other day.
4. Check INR daily until range is 2.0-3.0, then drop dose to 4mg
daily.
5. Weekly labs to include CK, LFTs, Bun, creatinine and CBC. The
results of these labs should be faxed to the infectious disease
clinic at [**Telephone/Fax (1) 1419**] attention: Dr [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **].
Medications on Admission:
Home Medications:
Coumadin 4mg PO daily
Lantus 18 units SQ QHS
Novolog sliding scale
Methocarbamol 1g PO Q4hours
Dilaudid 4mg PO Q4h PRN Pain
Atarax 25mg PO Q6H prn Pain
Miralax 17g PO BID PRN Constipation
Albuterol PRN
Vitamin C 500mg PO Daily
MVI
Lasix 20mg PO BID
Metoprolol 25mg PO BID
Omeprazole 20mg PO BID
Simvastatin 20mg PO QHS
Lisinopril 5mg PO Daily
.
Transfer Medications from [**Hospital3 **]:
Linezolid 600mg PO Q12
Allopurinol 200mg PO BID
Miconazole topical [**Hospital1 **]
Robaxin 500mg PO Q6
Ertapenem 1g IV Daily
Dilaudid 0.5mg IV Q2hr PRN
Levemir 10 units SQ QHS
Colac 100mg PO BID
Ventolin 1 puff Q4
Novolog Sliding Scale
Ferrous Sulfate 325mg PO BID
Simvastatin 20mg PO Daily
Metoprolol 25mg PO BID
Omeprazole 40mg PO daily
Senna 2 Tabs PO BID
MVI 1 tab PO Daily
Ascorbic Acid 500mg PO BID
Mylanta 30mL Q4 PRN
Tylenol 650mg PO Q4H PRN pain
Zofran 4mg IV Q6 PRN
Discharge Medications:
1. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain, headache.
4. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
5. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: 2-8 units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every
24 hours).
7. Fentanyl 100 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
9. Daptomycin 500 mg Recon Soln [**Hospital1 **]: Six Hundred (600) mg
Intravenous q48 hours for 13 days: LAST DOSE [**2177-7-8**].
10. Cefepime 1 gram Recon Soln [**Month/Day/Year **]: One (1) gm Injection once a
day for 13 days: ON HD DAYS, GIVE AFTER HD. LAST DAY = [**2177-7-8**].
11. Coumadin 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
12. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One Hundred (100) mg
PO BID (2 times a day).
13. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
injection Injection TID (3 times a day): please discontinue once
INR >2.
15. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Hydromorphone 4 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Epogen 10,000 unit/mL Solution [**Last Name (STitle) **]: 5500 (5500) units
Injection qHD.
19. Outpatient Lab Work
INR daily until therapaeutic ([**1-1**])
20. Outpatient Lab Work
CBC with differential, Chem-10, LFT, CK Qweek and fax results
to:
1. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (oncology) at ([**Telephone/Fax (1) 6023**].
2. Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1419**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Osteomyelitis
Hypoxic respiratory failure requiring intubation
Chronic respiratory failure requiring tracheostomy
Pneumonia
Chronic myelogenous leukemia
Renal failure requiring hemodialysis
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was our pleasure to participate in your care Mr. [**Known lastname 47031**]. You
were admitted to [**Hospital1 18**] for osteomyelitis. You were soon
transferred to the ICU for respiratory distress which was
likely due to fluid overload and pneumonia. You required
intubation with subsequent chronic respiratory failure requiring
tracheostomy. You were treated with broad spectrum antibiotics
for the osteomyelitis and pneumonia with a plan to continue a
course until [**2177-7-2**].
You developed acute renal failure and were evaluated by the
nephrology service. You required initiation of hemodialysis.
You developed a heart arrhythmia called ventricular tachycardia
and were evaluted by the electrophysiology service. This was
likely due to a medication you were on (ketamine), as it
resolved once the medication was stopped. You were started on
metoprolol to maintain the normal heart rhythm.
Your white [**Month/Day/Year **] cell count was found to be very high,
concerning for leukemia. YOu were evaluated by the
hematology-oncology team. Bone marrow biopsy was suggestive of
chronic myelogenous leukemia. You received plasmapharesis and
were started on a medication called gleevac. Your [**Month/Day/Year **] count
normalized and you will follow up with the hematology oncology
team for further management.
Followup Instructions:
1. You will follow up in the hematology oncology clinic with Dr.
[**Last Name (STitle) **] on [**7-8**] at 10:30AM. The phone number is
[**Telephone/Fax (1) **]. You should have your CBC, Chem-10 checked weekly
with the results faxed to attn: Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6023**].
2. You will follow up in the infectious disease clinic with Dr
[**Last Name (STitle) 12838**] on Tuesday, [**7-8**] at 3pm. You should remain on
daptomycin and cefepime until your appointment on [**7-8**].
While on Daptomycin and cefepime, you should have weekly labs to
include CK, LFTs, Chem-10, and CBC. The results of these labs
should be faxed to the infectious disease clinic at [**Telephone/Fax (1) 1419**]
attention: Dr [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **].
ICD9 Codes: 5849, 2761, 4271, 2851, 5789, 5990, 4280, 4168, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4414
} | Medical Text: Admission Date: [**2115-5-23**] Discharge Date: [**2115-5-31**]
Date of Birth: [**2036-2-24**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Hospital transfer- originally admitted to [**Hospital1 2177**] for "heartburn".
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2115-5-28**] with stenting of the left
circumflex artery.
History of Present Illness:
79 yo F c h/o CAD s/p stent placement in [**2111**] originally
presented to OSH c/o epigastric pain which pt. originally
attributed to "heart burn". The pain, however, was not relieved
by antacids as usual. The pt. denied chest pain, SOB, N/V,
diaphoresis. Pt. was taken to [**Hospital1 2177**] where it was discovered that
she had ST elevations in V1-V3 and reciprocal depressions in II,
III, and aVF. She was taken to the cath lab and found to have
total occlusion of proximal LAD. Pt. had instant relief of pain
following stenting of this vessel. Subsequent serial
echocardiograms showed declining LVEF from 40 to 30 to 20% c
severe akinesis of apex. During her hospital course, pt.
developed dyspnea and wheezing which was felt to be cardiac in
etiology. She responded well to diuresis. She was transferred
to [**Hospital1 18**] for further care.
Past Medical History:
CAD- cardiac catheterization and stenting in [**2-21**] and [**4-26**]
HTN
detrusor instability
osteoarthritis
hyperlipidemia
chronic bronchitis
anemia
GERD
questionable history of seizures
Social History:
Pt. lives c daughter on [**Location (un) 1773**] apartment. Denied use of
tobacco, EtOH, or IV drugs.
Family History:
Pt's. parents both died at young age (pt. did not remember exact
cause). She has a sister with CAD.
Physical Exam:
Vitals: T: 99.9 BP: 100/60 P: 73 R: 20 SaO2: 96%
General: pt. in NAD, alert
HEENT: PERRL, EOMI, MMM, + lingual thrush
Neck: JVD at 8 cm, supple, no bruits bilaterally
Chest: decreased breath sounds at bases, moderate end-expiratory
wheezes bilaterally.
Cardiac: RRR, S1S2S3, no m/r/g
Abdomen: obese, soft, NT/ND, no HSM, no fluid shift or wave
Extremities: no c/c bilaterally, bilateral LE edema to knees, no
sacral edema. 1+ DP and PT pulses bilaterally
Neurologic: Pt. a and o x 3, CN grossly intact, no focal
deficits appreciated
Skin: no rashes noted.
Pertinent Results:
[**2115-5-24**] 07:10AM BLOOD WBC-8.0 RBC-3.57* Hgb-10.9* Hct-31.8*
MCV-89 MCH-30.6 MCHC-34.3 RDW-14.6 Plt Ct-312
[**2115-5-24**] 07:10AM BLOOD Plt Ct-312
[**2115-5-24**] 07:10AM BLOOD Glucose-121* UreaN-20 Creat-0.9 Na-141
K-3.7 Cl-100 HCO3-30* AnGap-15
[**2115-5-24**] 07:10AM BLOOD Calcium-8.6 Phos-2.6*# Mg-2.3
Brief Hospital Course:
The pt. was admitted to the cardiac medicine service and placed
on telemetry. For the first five days of her hospital stay, the
goal was diuresis to improve her respiratory symptoms which were
thought to be due in part to congestive heart failure and
subsequent pulmonary edema superimposed on pre-existing COPD. On
the first hospital day, the pt. was placed on a nesiritide drip
and IV lasix. When it was noted that her blood pressure dropped
signigificantly over the course of 24 hours, nesiritide was
discontinued on the second hospital day. She was therefore
maintained only on IV lasix for diuresis. She responded
minimally to diuretic therapy, maintaining a marginally negative
fluid balance and showing slight improvement in LE edema and
pulmonary symptoms. On the sixth hospital day, the pt. was
scheduled to undergo cardiac catheterization. Prior to the
procedure, she developed significant respiratory distress while
attempting to remain supine for the procedure. Thus the the pt.
was given nebulizer treatments and the procedure was cancelled.
While in the holding area, however, the pt. was noted to respond
well to the nebulizer treatments, and the catheterization was
undertaken. The end result of the procedure was PTCA/stenting of
her left circumflex artery. As the pt. experienced significant
respiratory symptoms and a transient drop in blood pressure near
the time of the procedure, she was brought to the CCU after the
procedure where she remained for one day. Her brief stay in the
CCU was uneventful. She was judged to be in stable condition on
the seventh hospital day and was transferred back to the floor.
She remained on telemetry for the next two hospital days without
incident. She was discharged to a rehab facility in stable
condition.
Medications on Admission:
ASA 325mg po qd
plavix 75mg po qd
lipitor 40mg po qd
atenolol 100mg po qd
phenytoin 200mg po bid
detrol 4mg po bid
lasix 40mg po qd
lisinopril 40mg po qd
flovent 44mcg/p 2puffs ih [**Hospital1 **]
promethazine 12.5mg IV q6h prn
protonix 40mg po qd
oxybutynin 5mg po tid
advair 250/50 inh [**Hospital1 **]
colace 100mg po bid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
8. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: [**11-23**] Inhalation Q6H
(every 6 hours) as needed.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Nystatin 100,000 unit/mL supsension sig: 5 mL po qid
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
ST-elevation myocardial infarction
congestive heart failure
Type 2 diabetes mellitus
Chronic obstructive pulmonary disease
Discharge Condition:
Stable.
Discharge Instructions:
Please continue to take your medications as prescribed. If you
experience any concerning symptoms such as severe shortness of
breath, chest pain, or heartburn not relieved by antacids,
please call your primary care doctor or go to the nearest
emergency department. Refrain from strenuous activity for 2
weeks. Follow-up with your primary care physician and
cardiologist within 2 weeks.
Followup Instructions:
Follow-up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks.
Follow-up with your cardiologist within 2-3 weeks.
ICD9 Codes: 4280, 496, 4168, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4415
} | Medical Text: Admission Date: [**2197-3-13**] Discharge Date: [**2197-3-27**]
Date of Birth: [**2134-4-25**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
transfer from outside hospital, s/p STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization, BMS X4 to RCA
History of Present Illness:
62 year old man with a PMH of hypertension called 911 with a
complaint of chest pain and shortness of breath. In the field,
EMS found him in respiratory distress and attempted nasal
intubation which was partially successful. Also found to be
bradycardic and hypotensive. Taken to ED, EKG with new LBBB and
...inferior ST elevations. Initial enzymes CPK 255, troponin
0.129. Pt's CXR with pulmonary edema and ABG 7/17/50/50. Patient
orally intubated by anaesthesia. SBP elevated post Aspirin 300
PR, Plavix 600 given along with [**First Name3 (LF) **] gtt 8000 units Extensive
nasal bleeding seen and this was ballooned by ER physician.
[**Name10 (NameIs) **] gtt stopped although integrilin continued. Pt also given
20 IV lasix.
Pt taken emergently to catheterization, RHC with RVEDP 18, PCWP
16, LVEDP 22.
LHC with diffuse L main lesion down to bifurcation, 90% mid LAD
lesion, and 80% RCA lesion with thrombus. During procedure pt
given 40 IV lasix for elevated LVEDP. LV gram 40-45% apical and
anterior wall hypokinesis. He became hypotensive and was started
on neosynphrine drip subsequently transitioned to levophed.
.
Pt transferred to [**Hospital1 **] for further care. Of note had continued
oropharyngeal bleeding
Past Medical History:
Hypertension
Schizophrenia
Social History:
Patient has been estranged from borther over past three years.
He has not visited a doctor in years.
Family History:
unknown
Physical Exam:
T 97.9, BP 96/53 on 5 dopamine and .0175 of levophed, P 90-100
O2 sat 94-93 on AC TV 500 RR 26 FiO2 100 PEEP 14
.
Gen: Intubated, sedated.
Mouth: Bloody secretions suction from oropharynx
Neck: Trachea midline, JVP to 10 cm
Chest: Decreased breaths, less prominent on left
Cor: RR, aortic balloon sounds.
Abd: Obese
Ext: Cool, no edema, thready distal pulses
Radial: 1+ bilaterally
Femoral: R groin with venous sheath in place
L groin No bruit
PT: dopplerable
DP: dopplerable on L and R
Pertinent Results:
[**2197-3-13**] 01:56AM BLOOD WBC-21.3* RBC-6.38* Hgb-19.2* Hct-55.7*
MCV-87 MCH-30.1 MCHC-34.4 RDW-13.5 Plt Ct-428
[**2197-3-15**] 09:15AM BLOOD WBC-21.8* RBC-3.84* Hgb-11.4* Hct-32.5*
MCV-85 MCH-29.6 MCHC-35.0 RDW-13.9 Plt Ct-206
[**2197-3-13**] 01:56AM BLOOD PT-11.5 PTT-23.5 INR(PT)-1.0
[**2197-3-15**] 06:01AM BLOOD PT-13.5* PTT-60.0* INR(PT)-1.2*
[**2197-3-13**] 01:56AM BLOOD Glucose-128* UreaN-25* Creat-1.4* Na-138
K-5.2* Cl-103 HCO3-24 AnGap-16
[**2197-3-15**] 03:54AM BLOOD Glucose-150* UreaN-46* Creat-2.8* Na-138
K-3.8 Cl-105 HCO3-21* AnGap-16
[**2197-3-13**] 01:56AM BLOOD ALT-65* AST-322* CK(CPK)-3871* AlkPhos-68
TotBili-0.6
[**2197-3-13**] 08:13AM BLOOD CK(CPK)-4850*
[**2197-3-13**] 06:28PM BLOOD CK(CPK)-3466*
[**2197-3-14**] 03:44AM BLOOD CK(CPK)-3110*
[**2197-3-13**] 01:56AM BLOOD CK-MB-377* MB Indx-9.7* cTropnT-4.87*
[**2197-3-13**] 08:13AM BLOOD CK-MB-368* MB Indx-7.6* cTropnT-13.18*
proBNP-6467*
[**2197-3-14**] 03:44AM BLOOD CK-MB-44* MB Indx-1.4
[**2197-3-13**] 01:56AM BLOOD Calcium-8.9 Phos-5.7* Mg-2.2
[**2197-3-15**] 03:54AM BLOOD Calcium-7.5* Phos-2.7# Mg-2.0
[**2197-3-15**] 06:01AM BLOOD Vanco-21.1*
[**2197-3-13**] 04:59AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2197-3-13**] 04:59AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2197-3-13**] 04:59AM URINE RBC-[**1-25**]* WBC-[**1-25**] Bacteri-FEW Yeast-NONE
Epi-0-2
.
CHEST (PORTABLE AP) [**2197-3-13**] 4:10 AM
CHEST (PORTABLE AP)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with STEMI, hypoxia.
REASON FOR THIS EXAMINATION:
interval change
HISTORY: Hypoxia.
Single portable radiograph of the chest demonstrates marked
opacification of the bilateral lungs. Finding is unchanged when
compared with the chest radiograph obtained two hours prior.
Support lines are unchanged. No pneumothorax. The endotracheal
tube tip remains 2-3 cm above the level of the carina. There is
blunting of the bilateral costophrenic angles. No pneumothorax
is appreciated. The cardiomediastinal contours are obscured. The
left diaphragmatic contour is obscured as well.
IMPRESSION:
Persistent marked opacification of the bilateral lungs. The
finding may simply represent severe pulmonary edema. Possibility
of pneumonia or even an underlying mass is not excluded given
the extensive opacification.
Support lines in place.
.
Echo [**3-13**]
The left atrium is normal in size. There is moderate left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 15-20 %). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve is not well seen. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate LV hypertrophy. Severe global left
ventricular hypokinesis/akinesis - the basal segments and
lateral wall have the least poor function. Mild global RV
hypokinesis. No significant valvular abnormality seen. Moderate
pulmonary artery systolic hypertension.
.
ECG:
Sinus tachycardia. Prior inferior myocardial infarction. Prior
anteroseptal
myocardial infarction. ST segment depressions and T wave
inversions in
leads I and aVL. Slight ST segment elevation in leads II, III,
aVF and V2-V6 as recorded on [**2197-3-13**]. The rate has increased.
Followup and clinical
correlation are suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 142 90 340/427 61 49 125
.
ECG
Sinus tachycardia. The previously mentioned multiple
abnormalities persist.
There is variation in precordial lead placement. The axis is
more leftward.
The T waves are now biphasic in leads V4-V6 which may represent
further
evolution of ongoing myocardial infarction. Clinical correlation
is suggested.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 144 90 340/427 51 10 137
.
Cardiac cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed severe three vessel coronary artery disease. The LMCA,
LAD,
and LCX were not injected. The RCA had serial 99% lesions in
mid and
distal segments with distal PDA totally occluded.
2. Resting hemodynamics revealed normal right and left sided
filling
pressures with RVEDP of 10 mm Hg and PCWP mean of 12 mm Hg.
There was
moderate pulomary arterial hypertension of 38/20 mm Hg. The
cardiac
index with IABP and vasopressors was 2.5 l/min/m2.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Cardiogenic Shock.
.
Echo [**3-14**]
There is symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild to moderate
regional left ventricular systolic dysfunction with inferior
akinesis/hypokinesis and probably focal apical hypokinesis
(views suboptimal). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). The left ventricular inflow
pattern suggests impaired relaxation.
Compared with the prior study (images reviewed) of [**2197-3-13**],
left ventricular systolic function is improved.
.
CHEST (PORTABLE AP) [**2197-3-15**] 8:08 AM
CHEST (PORTABLE AP)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with STEMI, cardiogenic, septic shock.
REASON FOR THIS EXAMINATION:
interval change
INDICATION: 62-year-old male with STEMI, evaluate for change.
COMPARISON: [**2197-3-14**].
PORTABLE CHEST RADIOGRAPH: Aortic balloon pump marker seen
approximately 5.4 cm from the top of the aortic arch.
Endotracheal tube seen with tip approximately 4 cm above the
carina. Swan-Ganz catheter again seen with tip at the main
pulmonary artery. Nasogastric tube seen coursing over the
stomach, tip incompletely imaged. There is improving pulmonary
edema compared to yesterday's study. Increasing retrocardiac
opacity likely represents combination of atelectasis and
left-sided pleural effusion.
IMPRESSION:
1. Aortic balloon pump marker tip approximately 5 cm from the
top of the aortic arch. This could be advanced approximately 2
cm for more optimal placment. Discussed with Dr. [**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) 29932**]
at 11:30 a.m., [**2197-3-15**].
2. Improving pulmonary edema.
3. Increase in retrocardiac opacity likely representing a
combination of atelectasis and effusion.
Brief Hospital Course:
62 year old gentleman with HTN, no known previous history now
found in cardiogenic shock with three vessel disease.
#) Cardiogenic shock/CAD: Patient presented from OSH in
cardiogenic shock, intubated, on balloon pump and on
neosinephrine. EKG showed anterior and inferior Q waves, ST
elevations of inferior leads and aVR, and lateral ST
depressions. His neosinephrine was switched to dopamine and
norepinephrine. His CXR showed complete white-out of both lung
fields, thought secondary to pulmonary edema from cardiogenic
shock, and aspiration pneumonitis. On the vent, he was
ventilating well but was difficult to oxygenate. His vent
settings were therefore switched to allow minor hypercapnia to
allow increased PEEP and improved oxygenation, similar to ARDS
net protocol. He was started on a lasix drip. Initial echo
showed LVEF 15%. CK's peaked at 4800. Cardiac Catheterization
from outside hospital showed severe three vessel disease, with
collaterals from RCA to LAD, and active thrombus in the RCA. He
was evaluated by CT surgery, who did not want to take him to
surgery because they felt he was too high risk. He was
therefore taken for cardiac catheterization and received BMS X4
to his RCA. The following day, after coronary intervention, his
echo had an LVEF of 40%. Over the next several days, his
hemodynamics improved and his pressors were weaned off. His
aortic balloon pump was discontinued after being in place for
three days. He was continued on aspirin, plavix, metoprolol,
captopril, and atorvastatin and will continue with these
medications at home. He was followed by CT surgery throughout
his hospital stay and he will follow up with Dr. [**Last Name (STitle) **] for
likely CABG in the near future.
#) Ventilator Associated Pneumonia: Patient was extubated the
morning of [**3-18**]. Did well for most of the day, initially refused
to take medications because he insisted he would have a bad
reaction to them, later on in the day he agreed to take his
meds. He reported not feeling well. Later in the evening he
became more confused, claiming to have bowel movements and
asking the nurse to check, yet he did not have any bowel
movements. At around midnight, the patient began
hyperventilating to rates in the 50's. ABG was 7.47/37/68. CXR
with possible increased left sided infiltrate. ekg unchanged.
Patient was given lasix 20IV. Hyperventilation was initially
thought secondary to anxiety, he was given haldol .25mg IV and
ativan 1mg IV X1. patient persisted with hyperventilation. 30
minutes later patient was somnolent, difficult to arouse, ABG
7.43/39/87. Patient was intubated as he appeared to be tiring.
ABG's suggestive of increased CO2 production or increased dead
space. CT scan and CXR were consistent with Multi-lobar
Pneumonia thought to be due to VAP. He was started on zosyn and
continued on vancomycin (started previously for fevers).
Ciprofloxacin was added a few days later for continued fevers.
He was extubated successfully and transferred to the medical
floor. Vancomycin and Zosyn were then discontinued and he is to
complete a 7day course of Ciprofloxacin
#) Thrombocytosis: Mr. [**Name13 (STitle) 4698**] developed thrombocytosis during
this hospital stay. Platelets reached a peak of 1336. This was
thought to be secondary to reactive thrombocytosis due to
Pneumonia and STEMI. Heme/Onc was consulted given his high risk
status in order to rule out other possible causes such as
Polycythemia [**Doctor First Name **]. Mr. [**Name13 (STitle) 4698**] was polycythemic to 55.7 on
admission, however this quickly resolved and he was actually
anemic for most of his hospital stay. Plavix was increased to
75mg [**Hospital1 **] for prevention of thrombosis of his BMS x 4. A JAK 2
level was sent for evaluation of possible polycythemia.
Reactive Thrombocytosis is still the most likely cause of his
elevated platelet count. He will follow up in the general
[**Hospital 97388**] clinic regarding this matter.
#)ARF: Patient developed acute renal failure with progressively
increasing creatinine up to 2.8 after being hospitalized for
three days. Thought secondary to IV dye load, in addition to
possible intraaortic balloon pump placement which was shown to
be placed too low on CXR. His renal function began to improve
once the balloon pump was removed, and his creatinine decreased
to a level of 1.0 prior to discharge.
#) Oropharyngeal bleeding: He was seen by ENT, who performed
nasal packing. Nasal packing removed on [**3-17**]. Patient was
maintained on mupirocin while the pack was in place.
#) Psychiatric: Mr. [**Known lastname 97389**] brother gave a history of
schizophrenia, however the patient denied this diagnosis.
Psychiatry was consulted and believed that the patient did NOT
have schizophrenia.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute STEMI- inferior MI s/p stent to RCA
Ventilator associated pneumonia
Systolic CHF with EF 40%
Discharge Condition:
Stable, planning for CABG in next few weeks.
Discharge Instructions:
You were admitted with a large heart attack. You had a cardiac
catheterization to have a stent placed in the arteries of your
heart to open them up. You were also intubated for several days
and required another intubation for a multi-focal pneumonia
leading to respiratory distress.
Because of the new stent in your heart artery, you must take
aspirin 325mg daily and plavix 75mg twice daily every day
without stopping. Please DO NOT stop these medications without
talking to your cardiologist first.
Please continue to take your other medications as prescribed.
Please call your PCP or go to the emergency room if you have
fevers over 102, chills, chest pain, trouble breathing, or any
other symptoms which are concerning to you.
Followup Instructions:
Hematology - Please follow with your new Hematologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] : [**Telephone/Fax (1) 22**]. Date/Time: [**2197-4-7**] 1:00pm.
Cardiology - Please follow up with the [**Hospital1 **] cardiology team
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1159**] on [**2197-4-7**] 9:30am. Phone [**Telephone/Fax (1) 6256**]
CT Surgery: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD Ph: ([**Telephone/Fax (1) 40409**]. Date/Time: [**2197-4-12**] at 01:00pm.
ICD9 Codes: 5070, 5849, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4416
} | Medical Text: Admission Date: [**2154-7-10**] Discharge Date: [**2154-7-16**]
Date of Birth: [**2078-11-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Right colon mass
Major Surgical or Invasive Procedure:
Right colectomy with primary hand-sewn anastomosis side-to-side
of distal ileum to transverse colon
History of Present Illness:
75 had an episode of
appendicitis possibly perforated in [**2153-1-11**] treated at
[**Hospital 4415**]. She then went back to [**Country 651**] and
at that time continued to have weight loss and blood in her
stools. Eventually she got a colonoscopy in [**Country 651**] in [**2154-5-12**] and that showed a malignant appearing neoplasm in the
right colon. She was advised to have surgery but wanted to
come back to the United States and have her surgery here. So
she came back to the United States where she was found on
second attempt colonoscopy again to have a right colonic
malignant neoplasm and on a CT scan it appeared like quite a
large circumferential cecal mass with a mucocele of the
appendix.
Past Medical History:
HTN
increased cholesterol
history of "racing heart"
Social History:
She currently is not working. She does not smoke or drink any
alcohol. She takes some herbal products the name of which is
unknown. She also has fish oil and multivitamins.
Family History:
noncontrib
Physical Exam:
On discharge
Afebrile
NAD, A&Ox3
RRR
CTAB
soft nontender, nondistended
well healing midline scar
no lower extremity edema
Pertinent Results:
[**2154-7-15**] 06:20AM BLOOD WBC-7.1 RBC-3.60* Hgb-9.8* Hct-29.7*
MCV-83 MCH-27.2 MCHC-32.9 RDW-16.3* Plt Ct-416
[**2154-7-15**] 06:20AM BLOOD Plt Ct-416
[**2154-7-14**] 06:05AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-141
K-4.2 Cl-107 HCO3-26 AnGap-12
[**2154-7-12**] 06:00AM BLOOD CK(CPK)-344*
[**2154-7-12**] 02:40PM BLOOD CK(CPK)-290*
[**2154-7-13**] 04:21AM BLOOD CK(CPK)-212*
[**2154-7-12**] 06:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-7-12**] 02:40PM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-7-13**] 04:21AM BLOOD CK-MB-2 cTropnT-<0.01
.
pCXR [**2154-7-12**]:
Left mid lung atelectasis. No evidence of pneumonia or CHF.
.
Pathology pending at the time of d/c
Brief Hospital Course:
Pt tolerated the procedure well and was transferred to the
surgical floor the night of operation. In the early morning of
POD 2 the pt went into Afib w/ RVR (HR 110-170 and SBP 120) and
experienced some chest tightness. Pt has a history of similar
episodes (assumed to be pAF) and was seen by Cardiology. They
started her on Atenolol and did not want to start antiarrhythmic
drugs. Lopressor and Dilt push slowed the rate to 100's. CXR,
EKG, and cardiac enzymes were sent and no evidence of PNA or MI
were noted. She was transferred to the SICU for a dilt drip.
She converted to sinus within hours and was transitioned to PO
dilt. On POD 3 she was transferred back to the surgical floor.
She remained stable in NSR for the remainder of her stay. She
did well and past flatus on POD 4. A clear diet was started and
was tolerated. Her diet was advanced. She had a bowel movement
on POD 5. Pt ambulated without difficulty. She was d/c'd home
on POD 6 in good condition. The atenolol and diltiazem were
continued. Her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] ([**Telephone/Fax (1) 8236**]), was contact[**Name (NI) **] and
they will arrange a follow up appointment.
Medications on Admission:
Atenolol 100 mg Po QDay
Iron
Discharge Medications:
1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Malignant neoplasm of right colon, mucinous with mucin in
abdomen
2. post-op Afib
3. HTN
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath,
fever greater than 101.5, foul smelling or colorful drainage
from your
incisions, redness or swelling, severe abdominal pain or
distention,
persistent nausea or vomiting, inability to eat or drink, or any
other
symptoms which are concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from
your incisions, cover with a dry dressing. Leave white strips
above your incisions in
place, allow them to fall off on their own.
Activity: No heavy lifting of items [**11-25**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener,
Colace 100 mg twice daily as needed for constipation. You will
be given pain
medication which may make you drowsy. No driving while taking
pain medicine.
Followup Instructions:
[**Name6 (MD) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**] Date/Time:[**2154-7-22**] 9:30
Please follow up with your PCP within one week.
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4417
} | Medical Text: Admission Date: Discharge Date: [**2190-11-2**]
Date of Birth: [**2190-10-29**] Sex: M
Service: NEONATOLOGY
HISTORY AND PHYSICAL: 2185 gram product of a 34 and 5/7
weeks gestation, born to a 35 year old, Gravida I, Para 0
mother, with prenatal screens 0 negative, (treated with
RhoGAM); antibody negative; Rubella immune; RPR nonreactive;
hepatitis B surface antigen negative; GBS unknown. Pregnancy
complicated by twin gestation, cervical shortening at 25
weeks. Beta complete at that time. Spontaneous rupture of
membranes on [**10-29**] of twin number one. Infant born by
cesarean section. Infant received positive pressure
ventilation for less than one minute with improvement in
respiratory drive and color. Apgars were six at one minute
and nine at five minutes. The infant was transferred to the
Neonatal Intensive Care Unit for management of prematurity.
PHYSICAL EXAMINATION: Birth weight 2185 grams (50th
percentile); length 46 cm (50th percentile); head
circumference 25 cm (50th percentile). Normocephalic.
Anterior fontanel open and flat. Red reflexes present
bilaterally. Neck supple. Regular rate and rhythm. No
murmur. Femoral pulses 2 plus bilaterally. Abdomen soft
with active bowel sounds, no masses or distention. Normal
premature male genitalia. Testes in inguinal canal. Anus
patent. Spine midline. No sacral dimple. Hips stable.
Clavicles intact. Extremities: Warm and well perfused.
Brisk capillary refill. Normal tone for gestational age.
HOSPITAL COURSE: Infant has remained in room air throughout
this hospitalization with oxygen saturations greater than 95
percent. Infant has not had any apnea or bradycardia this
hospitalization.
Cardiovascular: Infant has remained hemodynamically stable,
no murmur.
Fluids, electrolytes and nutrition: Infant was started on D-
10-W shortly after admission for a dextrose stick of 46.
Glucoses have remained stable in the 70's. Enteral feedings
were started on day of life one. Infant is currently
receiving 120 cc per kg per day of breast milk 20 calories
per ounce or Similac Special Care, 20 calories per ounce,
po/pg. The most recent weight is 2110 grams.
Gastrointestinal: Infant received phototherapy for a peak
bilirubin level on day of life two of 10.2 with direct of 0.3.
Phototherapy was discontinued on the day of transfer; repeat
bilirubin is recommended in 24 hours.
Hematology: CBC on admission revealed white blood cell count
of 9,100; hematocrit of 55.3 percent; platelets 241,000. 18
neutrophils, 2 bands.
Infectious disease: Infant has not received antibiotics this
hospitalization. Blood culture was sent on admission. Blood
culture remains negative to date.
Neurology: Normal neurologic examination.
Sensory: Hearing screen has not yet been performed but is
recommended prior to discharge home.
Psychosocial: Parents involved.
CONDITION ON DISCHARGE: Four day old, 34 and [**6-18**] week twin
number two, stable in room air.
DISCHARGE DISPOSITION: To level II nursery at [**Hospital3 1280**]
Hospital.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 57450**], telephone
number [**Telephone/Fax (1) 46981**].
CARE AND RECOMMENDATIONS: Feedings at discharge: 120 cc per
kg per day of breast milk 20 calories per ounce or Similac
Special Care 20 calories per ounce po/pg.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Recommended prior to discharge
home.
STATE NEWBORN SCREEN: Sent on day of life three. Results
are pending.
IMMUNIZATIONS: Hepatitis B is recommended prior to
discharge.
DISCHARGE DIAGNOSES:
1. Prematurity, 34 and [**6-18**] week, twin number two.
2. Rule out sepsis.
3. Indirect hyperbilirubinemia.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 57000**]
MEDQUIST36
D: [**2190-11-2**] 00:59:52
T: [**2190-11-2**] 04:54:06
Job#: [**Job Number 57452**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4418
} | Medical Text: Admission Date: [**2156-9-2**] Discharge Date: [**2156-9-9**]
Date of Birth: [**2083-12-27**] Sex: M
Service: SURGERY
Allergies:
Levofloxacin / Penicillins / Morphine Sulfate
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
RUQ pain, hypotension, and recurrent cholecystitis
Major Surgical or Invasive Procedure:
ultrasound-guided percutaneous cholecystostomy tube placement
History of Present Illness:
Mr. [**Known lastname 10733**] is a 72 yo male with a complicated cardiac history,
and EF of 20%. He presents now with RUQ pain and hypotension. He
is well known to Dr. [**Last Name (STitle) **] who has managed his recurrent
cholecystitis that have required percutaneous cholecystotomy
drainage. His was discharged home with a drain in place during
last admission. The drain fell out about 2 months ago. On day of
admission, her reported
Past Medical History:
S/P MI - NSTEMI [**2144**], S/P CABGX4 with a LIMA to the LAD and vein
graphs to his PDA, and sequential graphs to the first diagonal
and obtuse marginal
CHF LVEF 10-20% - ischemic cardiomyopathy
s/p Biventricular ICD implantation
DM diagnosed in [**2130**] - has been insulin for approx. 25 years.
GB stone h/o cholangitis, s/p choledochostomy tube
Peripheral Viscular Disease - Right foot transmetatarsal
amputation, [**2153**], a right femoral popliteal bypass - [**2151**]
H/O stroke, [**2145**] - MRI here demonstrated a left pontine stroke
with a history of a right hemiparesis and dysphasia
Social History:
Lives with wife; no tob/illicits. Previous 35 pk-year smoker
(quit 20 years ago).
Family History:
NC
Physical Exam:
Vitals in ICU: T-96.2, HR-66, BP-117/67, MAP-78, RR-23, O2
sat-99% on 3Liters NC
Gen: NAD, A/Ox3, comfortable
Neck: supple, no LAD, no bruits heard
Cardiac: RRR
Resp: CTAB, no rales noted
ABD: Distended, hypoactive bowel sounds, soft, nontender
throughout, no rebound or guarding, no scars or hernias, neg
[**Doctor Last Name **]
Elim: Foley in place.
Rectal guaiac negative, normal tone, no masses
Pertinent Results:
[**2156-9-6**] 05:45AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.0* Hct-27.2*
MCV-89 MCH-29.5 MCHC-33.1 RDW-16.6* Plt Ct-271
[**2156-9-2**] 06:58PM BLOOD WBC-10.8 RBC-3.30* Hgb-9.7* Hct-28.0*
MCV-85 MCH-29.3 MCHC-34.4 RDW-16.5* Plt Ct-221
[**2156-9-6**] 05:45AM BLOOD Plt Ct-271
[**2156-9-3**] 04:35PM BLOOD PT-14.7* PTT-29.3 INR(PT)-1.3*
[**2156-9-2**] 06:58PM BLOOD PT-13.5* PTT-27.8 INR(PT)-1.2*
[**2156-9-6**] 05:45AM BLOOD Glucose-244* UreaN-63* Creat-1.6* Na-136
K-4.9 Cl-107 HCO3-22 AnGap-12
[**2156-9-2**] 06:58PM BLOOD Glucose-93 UreaN-107* Creat-1.9* Na-127*
K-4.5 Cl-97 HCO3-19* AnGap-16
[**2156-9-6**] 05:45AM BLOOD ALT-32 AST-9 AlkPhos-232* Amylase-17
TotBili-0.2
[**2156-9-2**] 06:58PM BLOOD ALT-119* AST-87* CK(CPK)-33* AlkPhos-361*
Amylase-29 TotBili-0.3
[**2156-9-6**] 05:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
[**2156-9-2**] 06:58PM BLOOD Albumin-3.0* Calcium-8.2* Phos-5.3*
Mg-2.3.
.
[**2156-9-2**] 10:20 pm BILE
**FINAL REPORT [**2156-9-5**]**
GRAM STAIN (Final [**2156-9-3**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10734**] [**Last Name (NamePattern1) **] @ 2:30A [**2156-9-3**].
FLUID CULTURE (Final [**2156-9-5**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. PENICILLIN SENSITIVITY AVAILABLE ON
REQUEST.
ENTEROCOCCUS SP.. MODERATE GROWTH.
.
Urine and blood cultures-negative
.
RADIOLOGY Final Report
GUIDANCE PERC TRANS BIL DRAINAGE US [**2156-9-2**] 10:57 PM
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: GB SLUDE, DRAINAGE
IMPRESSION: Technically successful ultrasound-guided
percutaneous cholecystostomy tube placement (8 French).
.
RADIOLOGY Final Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2156-9-2**] 7:37 PM
Reason: assess for possible perc drainage, discussed with
radiology
IMPRESSION: Distended gallbladder containing sludge and debris
with thickened wall, findings that are consistent with acute
cholecystitis.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2156-9-2**] 7:11 PM
CHEST (PORTABLE AP)
Reason: pre-op
IMPRESSION: AP chest compared to [**7-6**] through [**7-16**]:
Mild cardiomegaly has improved, but borderline interstitial
edema and pulmonary [**Month (only) 1106**] congestion remain. There is no
pleural effusion. Transvenous right atrial and left ventricular
pacer leads and right ventricular pacer defibrillator lead are
in standard placements, unchanged, continuous from the left
axillary pacemaker. No pneumothorax or appreciable pleural
effusion is seen.
.
RADIOLOGY Preliminary Report
ART EXT (REST ONLY) [**2156-9-8**] 2:00 PM
Reason: Eval. for signs of [**Month/Day/Year 1106**] insufficiency
HISTORY: Necrotic left foot ulcer.
IMPRESSION: Significant right-sided tibial disease, left-sided
SFA and tibial disease. Findings are little changed compared to
the exam of 6/[**2153**].
Brief Hospital Course:
Mr. [**Known lastname 10733**] presented to [**Hospital1 18**] ED for work-up of RUQ pain and
hypotension. He was transferred to the SICU for blood pressure
management with vasopressors, correction of electrolyte
imabalances, IV hydration, and IV antibiotics.
.
CARDIAC:His blood pressure stabilized in the ICU, and he was
weaned from the vasopressors. His hemodynamic status normalized,
and he was transferred to [**Hospital Ward Name **] for further management of the
acute cholecystitis.He was transitioned back to his oral
medication regimen once he was able to tolerate PO fluids. His
blood sugars were elevated ranging 150-300's. Adjustments were
made to the regular sliding scale for tighter control with
positive affect, and he was restarted on his NPH and Humalog.
.
NUT:He remained NPO for a few days to aid in resolution of the
cholecystitis. His labwork returned to baseline, and his diet
was advanced to regular, cardiac/diabetic healthy diet. He was
tolerating regular food without complaints of nausea/vomiting.
.
ID:He underwent a RUQ Ultrasound at an outside hospital revealed
sludge, thickening, fluid around gallbladder. A repeat
ultrasound was obtained at [**Hospital1 18**] on [**2156-9-2**] which confirmed the
ultrasoud findings from the outside hospital, and the presence
of acute cholecystitis. He underwent a CT guided drainage of the
gallbladder which was sent for cultures & sensitivitied. His IV
antibiotic regimen was adjusted according to culture
sensitivities. He remained afebrile, and was transitioned to
oral Ampi and Cipro on [**2156-9-5**]. He will finish the 2 week
regimen at home.
.
GI/ABD:His abdomen is round and nontender, skin intact. He has
bowel sounds in all four quadrants. He reports passing gas. He
was started on a bowel regimen to promote a bowel movement. He
has a Right lower flank percutaneous pigtail drainage device.
The site is intact, and draining small amounts of bilious fluid.
He and his family were instructed on drain care and flushing at
discharge. He will follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
.
PAIN:He reports 0/10 pain presently. His RUQ pain has subsided.
He had been intially managed with IV Dilaudid with adequate
relief. He was transitioned to oral Dilaudid, and will be
discharged home with a 2 week supply to be used as needed.
.
EXTREM:He has a left non-infected necrotic foot ulcer that has
been managed per Dr. [**Last Name (STitle) 3407**] ([**Last Name (STitle) 1106**]) from some time. He was
seen by the [**Last Name (STitle) **] service during this admission. He underwent
ultrasounds of the lower extremeties which was unchanged from
the last report. He will follow-up with Dr. [**Last Name (STitle) 3407**] in 1 week to
set up an out-patient angiogram/venous studies.
Medications on Admission:
Insulin NPH 45(AM), humolog 5(PM); ASA 325; Lasix 80"; plavix
75'; isosorbide dinitrate 60'; coreg 25'; lipitor 20';
lisinopril 20'; colchicine 0.6"'; potassium
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
45 UNITS Subcutaneous QAM.
4. Humalog 100 unit/mL Solution Sig: One (1) 5 Units
Subcutaneous at bedtime.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
6. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
9. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for pain.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO MWF
(Monday-Wednesday-Friday).
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. 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*
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
16. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*80 Capsule(s)* Refills:*0*
17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
recurrent cholecystitis
Left non-infected necrotic foot ulcers
.
Secondary:
Ischemic cardiomyopathy w/LVEF 10-15%
Coronary artery disease
s/p Myocardial infarction
s/p CABG
Hypertension
Diabetes Mellitus Type II
Peripheral [**Company **] Disease
chronic renal insufficiency (baseline 1.4)
Discharge Condition:
Stable
Tolerating a regular, cardiac, diabetic diet
Adequate pain control with oral medication
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Restrict Fluid to 2 liters per day.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
*Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
1. Please call Dr.[**Name (NI) 1482**] office at [**Telephone/Fax (1) **] for a
follow-up appointment in 2 weeks.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2156-9-14**] 11:15
3. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2156-10-4**] 11:00
4. Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2156-10-19**]
11:00
5. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] [**Telephone/Fax (1) **] in 1 week
to review your cardiac medication regimen.
Completed by:[**2156-9-9**]
ICD9 Codes: 2761, 412, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4419
} | Medical Text: Admission Date: [**2177-7-13**] Discharge Date: [**2177-7-24**]
Date of Birth: [**2126-2-28**] Sex: M
Service: SURGERY
Allergies:
Codeine / Ciprofloxacin / morphine / fentanyl
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Hypoglycemia, decrease pulses bilateral lower extremities.
Major Surgical or Invasive Procedure:
[**2177-7-16**]: Right axillary-bifemoral bypass, bilateral femoral
endarterectomy and left lower extremity thrombectomy
History of Present Illness:
The patient is a 51-year-old gentleman who found unresponsive on
floor by his partner day of admission, [**2177-7-13**]. He had had a
decreased appetite over the prior 3-4 days He has not been
taking his insulin secondary to his poor PO intake. He was
taken by EMS to the [**Hospital1 18**] ED. En route, he was found to have a
blood sugar of 13 and was given d50 and glucagon. He was
intermittently hyper-and hypoglycemic with an elevated white
count, electrolyte abnormalities and rhabdomyolysis and was
admitted to the MICU for further care.
After his blood sugars were stabilized and his mental status
returned to baseline, he noted acute pain in his bilateral lower
extremities He was found to have an absence of signals in his
left lower extremity with only monophasic Doppler signals in the
right. He underwent a CT angiogram that demonstrated an
occlusion of his aorta at the level of his renal arteries, with
reconstitution of his right distal external iliac artery and his
bilateral femoral arteries. It was felt that he likely
thrombosed his already known diseased aortoiliac which led to
thrombosis of his left SFA in the setting of severe common
femoral disease. He therefore was brought to the OR for a right
axillary bifemoral bypass with femoral endarterectomies and
thrombectomy of his left lower extremity.
Past Medical History:
PMH: R ICA occlusion, DM, chronic pancreatitis, malnutrition,
ADHD, chronic pain, osteoporosis
PSH: Puestow '[**68**], G to J bypass '[**74**]
Social History:
Patient moved from VT to [**Location (un) 86**] with his husband last year seek
out better medical care. Has been with husband [**Male First Name (un) **] for 28
years. Used to work in manufacturing, unable to work recently.
Rare EtOH (once every few months) since pancreatitis diagnosis
in [**2167**]; prior to that was drinking [**2-28**] drinks/day for a few
years and had been drinking less heavily before that time.
Smokes 1.5 packs cigarettes/day. No history IVDU, remote
history of marijuana.
Family History:
Paternal grandmother and father with diabetes requiring multiple
amputations, maternal family history unknown.
Physical Exam:
Vitals:Afebrile, 140s, 108/73, 12, 100%RA
General: Alert, oriented, cachectic male, weak and ill appearing
in NAD.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear throughout
Abdomen: soft, non tender, bowel sounds present, no organomegaly
Skin: multiple ecchymotic areas on his arms bilaterally, with
small excorciations.
Pulses:Dopplerable DP/PT bilaterally.
Incisions: Bilateral groins stapled,slightly reddened, taut but
well approximated, some serous drainage. Right subclavian
incision stapled, slightly reddened, no drainage. Right chest
graft site, slightly red also.
Pertinent Results:
[**2177-7-24**] 06:55AM BLOOD WBC-10.4 RBC-3.31* Hgb-10.4* Hct-31.2*
MCV-94 MCH-31.3 MCHC-33.2 RDW-14.6 Plt Ct-326
[**2177-7-24**] 06:55AM BLOOD Neuts-69.3 Lymphs-25.7 Monos-3.3 Eos-1.3
Baso-0.4
[**2177-7-24**] 06:55AM BLOOD Glucose-208* UreaN-10 Creat-0.8 Na-136
K-4.0 Cl-100 HCO3-31 AnGap-9
[**2177-7-14**] 01:49AM BLOOD %HbA1c-8.2* eAG-189*
Brief Hospital Course:
The patient is a 51-year-old gentleman who found unresponsive on
floor by his partner day of admission, [**2177-7-13**]. He had had a
decreased appetite over the prior 3-4 days He has not been
taking his insulin secondary to his poor PO intake. He was
taken by EMS to the [**Hospital1 18**] ED. En route, he was found to have a
blood sugar of 13 and was given d50 and glucagon. He was
intermittently hyper-and hypoglycemic with an elevated white
count, electrolyte abnormalities and rhabdomyolysis and was
admitted to the MICU for further care. After his blood sugars
and electrolytes were stabilized and his mental status returned
to baseline, he noted acute pain in his bilateral lower
extremities
He was found to have an absence of signals in his left lower
extremity with only monophasic Doppler signals in the right. He
underwent a CT angiogram that demonstrated an occlusion of his
aorta at the level of his renal arteries, with reconstitution of
his right distal external iliac artery and his bilateral femoral
arteries. It was felt that he likely thrombosed his already
known diseased aortoiliac which led to thrombosis of his left
SFA in the setting of severe common femoral disease. He
therefore was brought to the OR ON [**2177-7-16**] for a right axillary
bifemoral bypass with femoral endarterectomies and thrombectomy
of his left lower extremity. The procedure was without
complications. He was closely monitored in the PACU and then
transferred to the floor where he remained hemodynamically
stable. His diet was gradually advanced. He is ambulatory with
ad lib. His hct and renall function are at baseline.
1. Diabetes
[**Last Name (un) **] was consulted for insulin management given labile blood
sugars. Once he was started on pos, he was given a sliding
scale using novolg to be given based on blood sugars taken 2
hours after eating. His BS have been well controlled. A1C was
8.2 on [**2177-7-14**].
2. ID
On [**2177-7-22**] as we was preparing for dicharge, it was noted that
his wbc had increased from 8K to 12K. He remained afebrile but
there was erythema noted over the graft so he was started
emprically on vanco. By [**2177-7-24**], BC were negative, erythema
resolved and wbc returned to [**Location 213**]. He is discharged on 1 week
on DS bactrim.
3. Pain management
Patient has chronic pain and is on a pain regimen at home which
includes Oxycontin 20mg [**Hospital1 **] with Oxycodone for breakthrough pain
(states was taking 15mg five times per day) so chronic pain
service was consulted for postop management. He was initially
managed with a PCA then titrated to po oxycontin/oxycodone. On
discharge, he have given him a 2 week supply of opiates and have
arranged for a followup appointment with his PCP for next week
for further pain management issues and titration to baseline of
his narcotics.
4. Anticoagulation
Post operatively, he was on a heparin gtt as a bridge to
coumadin. He will require long term anticoagulation on coumadin
that will be managed by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Medications on Admission:
Medications are from Feway records:
Oxycontin 20mg XR12H [**Hospital1 **]
Vitamin D 50,000 caps po qweek x 8 wks(not taking)
Oxycodone 5mg up to 3 tabs q 3-4hrs prn severe abd pain for
chronic pancreatitis pain
Methylphenidate CR 20mg po TID(not taking)
Creo [**Numeric Identifier 17514**] [**1-26**] with each main meal and [**11-25**] with snacks(not
taking)
Lantus 4u qAM (not taking)
Discharge Medications:
1. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN use for
breakthrough pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every 3 hours as needed
pain [**Month/Day (2) **] #*100 Tablet Refills:*0
2. Warfarin 1 mg PO DAILY16 Duration: 1 Doses
RX *warfarin [Coumadin] 1 mg 1 tablet(s) by mouth daily as
directed by Dr. [**Last Name (STitle) **] [**Name (STitle) **] #*60 Tablet Refills:*0
3. Oxycodone SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every 8
hours [**Name (STitle) **] #*50 Tablet Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily [**Name (STitle) **] #*14 Tablet Refills:*0
5. humalog insulin
Fingerstick QPC2HInsulin SC Sliding Scale Humalog
Glucose Breakfast Lunch Dinner Bedtime
71-159 mg/dL 0 Units 0 Units 0 Units 0 Units
160-199 mg/dL 2 Units 2 Units 2 Units 2 Units
200-239 mg/dL 3 Units 3 Units 3 Units 3 Units
240-279 mg/dL 4 Units 4 Units 4 Units 4 Units
280-319 mg/dL 5 Units 5 Units 5 Units 5 Units
320-359 mg/dL 6 Units 6 Units 6 Units 6 Units
360-399 mg/dL 7 Units 7 Units 7 Units 7 Units
400-439 mg/dL 8 Units 8 Units 8 Units 8 Units
440-479 mg/dL 9 Units 9 Units 9 Units 9 Units
480-519 mg/dL 10 Units 10 Units 10 Units 10 Units
Instructons for NPO Patients: Please check blood glucose 2 hours
after meals, and inject Humalog insulin per sliding scale above.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Hypoglycemia
Aortoiliac Occlusion
Diabetes
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 dangerously low blood
sugars. After the blood sugars were stablized, you were found to
have a blockage in your aorta that prevented adequate blood flow
into your into your legs. We needed to bypass the area and also
remove a blood clot from your left leg.
We have started you on a blood thinner called coumadin. It is
VERY IMPORTANT that you take this medication as prescribed and
have frequent blood draws to monitor the INR levels that are
effected by the coumadin. Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **] monitor the
blood levels and tell you the daily dosing of your coumadin.
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the legs :
?????? Elevate your legs above the level of your heart (use [**12-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision should be covered and dry at all time.
Followup Instructions:
[**Hospital1 778**] Health (Dr. [**Last Name (STitle) **] office)[**7-31**] at 10:50am. She
will renew your pain medication prescriptions.
Department: VASCULAR SURGERY
When: THURSDAY [**2177-8-7**] at 11:15 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2177-7-24**]
ICD9 Codes: 3572, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4420
} | Medical Text: Admission Date: [**2124-10-30**] Discharge Date: [**2125-1-3**]
Date of Birth: [**2077-6-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
End stage liver disease;primary sclerosing cholangitis with
resulting
cirrhosis.
Major Surgical or Invasive Procedure:
[**2124-10-30**]:Living unrelated liver transplantation
with right hepatic artery to right hepatic artery donor
recipient.
[**2124-11-30**]:Revision of Roux-en-Y hepaticojejunostomy
to right anterior hepatic duct, Tru-Cut biopsy of the liver,
intraoperative ultrasound, oversewing of right posterior
hepatic duct.
History of Present Illness:
Mr. [**Known lastname 23560**] is a 47-year-old
male with a history of primary sclerosing cholangitis. He
initially presented to us approximately 1-year ago where he was
taken to the operating room for a laparoscopic cholecystectomy
and liver biopsy. At that time, his symptoms were consistent
with cholecystitis and it was thought that a cholecystectomy
would overall improve his sense of well-being. The liver biopsy
that time demonstrated stage III stage IV fibrosis and he had no
postoperative complications. He has been followed by the
Transplant Center for the past year, during which time he has
had
a developed increasing jaundice and fatigue, and now presents
for
a live unrelated liver transplantation.
Past Medical History:
PMH:
1) Primary Sclerosing Cholangitis (PSC) - diagnosed in [**2122-3-25**];
secondary liver disease, as noted in liver biopsy results from
[**2122-8-28**] (above), with evidence of portal and peri-portal
fibrosis
with focal nodule formation
2) S/p cholecystectomy, [**2122-8-25**]
3) S/p nasal polypectomy - approximately 4 years ago (Dr.
[**Last Name (STitle) 1837**]; no significant history of sinus symptoms
4) H/o anal fistula - 15 years ago; s/p repair
5) Hyperlipidemia (not currently on lipid-lowering agents)
6) H/o of "bilateral interstitial pneumonia", in [**2122-9-25**],
Rx.'d with Azithromycin, followed by Clarithromycin
Social History:
Married (for 14 years), lives with wife and 4 children, in
[**Location (un) 15984**], [**Hospital3 4298**]. No known TB contacts.
Employed
as a retail pharmacist. No history of smoking. Previous
occasional social EtOH consumption for the past 10 years
(although admits to heavier EtOH consumption during college
years), but none since diagnosis of PSC ([**2122-3-25**]).
Family History:
Paternal grandmother diagnosed with primary biliary cirrhosis at
age [**Age over 90 **] y/o. Father deceased secondary to glioblastoma. Mother
currently alive (age 74 y/o) and well, with hypertension. Older
brother (2 years older), with Hepatitis C (for the past 2
years),
but currently otherwise healthy. Four children (4 sons), all
healthy (ages range from 2 y/o to 8-1/2 years old).
Physical Exam:
[**2124-10-25**] preop exam per documentation:
On physical examination, his blood pressure is 115/84, pulse 80,
respirations 20, temperature is 98.8, and his weight 153 pounds.
His chest is clear to auscultation and percussion bilaterally.
Cardiac exam is regular rate and rhythm murmur. His abdomen is
soft, nontender, and nondistended. He does have both
hepatomegaly and splenomegaly. I do not appreciate any
significant ascites. His trocar incisions from the laparoscopic
cholecystectomy has well healed nicely. There is no wound
breakdown or discharge. His femoral pulses are 2+ and equal
bilaterally. He has no peripheral edema.
Pertinent Results:
[**2125-1-3**] 05:47AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.3* Hct-28.1*
MCV-94 MCH-30.9 MCHC-33.0 RDW-18.3* Plt Ct-331
[**2125-1-3**] 05:47AM BLOOD ALT-66* AST-40 AlkPhos-880* TotBili-11.4*
[**2125-1-3**] 05:47AM BLOOD Glucose-146* UreaN-46* Creat-1.8* Na-132*
K-5.0 Cl-101 HCO3-21* AnGap-15
[**2124-12-27**] 05:58AM BLOOD PT-14.7* PTT-25.9 INR(PT)-1.4
[**2124-10-30**] 07:56PM BLOOD Glucose-179* UreaN-9 Creat-0.7 Na-144
K-3.8 Cl-104 HCO3-25 AnGap-19
[**2124-10-30**] 07:56PM BLOOD ALT-748* AST-939* AlkPhos-250* Amylase-23
TotBili-9.4* DirBili-6.3* IndBili-3.1
[**2124-11-22**] 07:05PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
TEST
[**2124-10-30**] 10:16AM BLOOD WBC-3.1* RBC-3.75* Hgb-11.9* Hct-34.7*
MCV-93 MCH-31.8 MCHC-34.3 RDW-16.7* Plt Ct-191
[**2124-12-1**] 11:45AM ASCITES WBC-1500* RBC-[**Numeric Identifier 23561**]* Polys-99* Lymphs-0
Monos-1*
[**2124-12-26**] 05:03PM ASCITES TotBili-142
[**2124-12-4**] 09:38AM ASCITES TotBili-119.0
[**2124-11-28**] 04:00PM ASCITES TotBili-21.3
[**2124-11-11**] 12:25PM ASCITES TotBili-8.9
[**2124-11-8**] 06:58PM ASCITES TotBili-7.1
[**2124-12-22**] 08:49PM OTHER BODY FLUID TotBili-33.8
MICROBIOLOGY
[**2124-11-22**] 10:35 am BILE MEDIAL T. TUBE.
VIRIDANS STREPTOCOCCI. HEAVY GROWTH.
ENTEROCOCCUS SP.. HEAVY GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
GRAM POSITIVE RODS. MODERATE GROWTH. UNABLE TO ID
FURTHER.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R VRE
[**2124-11-7**] 8:00 am BILE
KLUYVERA SPECIES. HEAVY GROWTH
_________________________________________________________
KLUYVERA SPECIES
|
CEFAZOLIN------------- 16 I
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
[**2124-12-14**] 10:39 pm BLOOD CULTURE
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
[**2124-11-7**] 8:30 am BLOOD CULTURE CVL.
KLUYVERA SPECIES.
_________________________________________________________
KLUYVERA SPECIES
|
CEFAZOLIN------------- 16 I
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
[**2124-11-7**] 8:30 am BLOOD CULTURE: KLUYVERA SPECIES.
[**2124-12-1**] 11:45 am PERITONEAL FLUID & PERITONEAL CLOT.
FLUID CULTURE ENTEROCOCCUS FAECIUM
VANCOMYCIN------------ =>32 R VRE
[**2124-11-22**] 7:05 pm Immunology (CMV) CMV DNA not detected.
LIVER BIOPSIES:
Procedure date Tissue received Report Date Diagnosed
by
[**2124-12-26**]
Fragmented biopsy with few portal areas showing mild mononuclear
cell inflammation. Focal bile duct proliferation with associated
neutrophils; cannot rule out biliary obstruction. No evidence of
acute cellular rejection. Prominent cholestasis.
[**2124-12-15**]
Indeterminate for acute cellular rejection; Bile duct
proliferation and cholestasis cannot exclude biliary
obstruction.
[**2124-12-1**]
Mild acute cellular rejection;Mild cholangitis with bile duct
proliferation;Mild cholestasis consistent with harvest injury.
[**2124-11-21**]
Mild acute cellular rejection with endotheliitis; Mild
cholestasis; The degree of rejection
[**2124-11-10**]
Moderate acute cellular rejection with mixed portal inflammation
with predominantly mononuclear cells, scattered neutrophils,
portal venular endothelialis, and focal central venular
endothelialitis; Cholestasis, central.
RADIOLOGY:
CT ABDOMEN W/O CONTRAST [**2125-1-2**] 9:04 PM
IMPRESSION:
In comparison with the most recent CT of [**2124-11-28**], the
large contrast- containing fluid collection has resolved. No
large fluid collections are identified within the abdomen and
pelvis, limited examination due to lack of oral or IV contrast.
DUPLEX DOPP ABD/PEL [**2125-1-1**] 1:47 PM
IMPRESSION:
Patent hepatic vasculature with normal Doppler waveforms as
above.
Interval decrease in previously evident mild biliary ductal
dilatation
[**Numeric Identifier 23562**] CHANGE PERC BILIARY DRAINAGE CATHETER [**2124-12-20**] 11:44 AM
A pull-out cholangiogram was performed outlining free passage
into the jejunum from the bile duct. The 6.3 biliary drainage
catheter was then placed across the anastomosis with good
results and free passage of contrast material into the jejunal
limb.
DUPLEX DOPP ABD/PEL [**2124-12-19**] 2:31 PM
IMPRESSION:Patent intrahepatic vasculature, as discussed above.
[**Numeric Identifier **] TUBE CHOLANGIOGRAM [**2124-12-14**] 7:27 AM BILIARY CATH CHECK
1. Antegrade cholangiogram to both biliary drains demonstrates
no evidence of leak. The anastomosis is widely patent.
2. Successful exchange of biliary drain to new 8-French
catheter. We plan to down-size it to a 6-French biliary drain in
the next few days.
3. Injection of contrast through the J-P drain fails to
demonstrate communication with the biliary tree.
MRCP (MR ABD W&W/OC) [**2124-12-9**] 6:17 AM
Overall unchanged appearance of the biliary system. There is no
evidence of worsening biliary ductal dilatation. There has been
interval placement of three biliary catheters, and both the
fluid signal intensity lesions within the liver, as well as
regions of focal arterial enhancement in the peripherqal zone
(not present 10 days ago) probably relates to post- traumatic
and hyperemic effects from the recent manipulation. Follow up
examination may be performed in six months, or as otherwise
clinically indicated; both the native and recipient hepatic
arteries demonstrate good vascular filling, although the
evaluation of the anastomosis is again limited by technical
factors; Decrease in the amount of ascites and there is less
fluid in the region of the hepatic hilum
[**Numeric Identifier 23563**] BILIARY STRICTURE DILATION NO STENT [**2124-12-7**] 7:34 AM
We were able to communicate the right posterior biliary system
to the bile duct; Successful balloon dilatation of the distal
segment of the right posterior duct; Successful placement of an
8-French biliary drain going through the anastomosis into the
bowel; No evidence of leak was seen.
TUBE CHOLANGIOGRAM [**2124-12-5**] 7:35 AM
IMPRESSION:
Right anterior biliary tree system demonstrating free flow of
contrast into the jejunum without evidence of narrowings,
obstruction, or extravasation of contrast; [**Last Name (un) 12170**] catheter
within the right posterior biliary tree system which does not
demonstrate any communication with the right anterior biliary
duct system nor does it drain into the jejunum. No evidence of
biliary duct dilatation or leakage of contrast from the right
posterior biliary duct system.
INTRO PERC TRANSHEPATIC STENT [**2124-11-29**] 9:10 AM
Status post percutaneous transhepatic biliary drainage of 3
segmental ducts, one of which was accomplished with passage
through the obstruction near the region of the anastamosis. Two
catheters are in place for external drainage only
.Approximately, 120 mL of bile was evacuated from the subhepatic
space through the pigtail catheter.
[**Numeric Identifier 23564**] CHALNAGIOGRAPHY VIA EXISTING CATHETER [**2124-11-28**] 7:29 AM
IMPRESSION:
1. Contained leak identified along the medial cut surface of the
liver which appears to connect to the smaller contained leak
identified on the prior cholangiogram. There is internal
drainage from this contained leak into the bowel.
2. Second perihepatic contained leak identified along the
inferior and lateral margin of the liver, which appears to
connect to the other contained leakage collections.
3. Biliary tree partially opacified due to probable retrograde
filling from the bowel. Compared to the prior cholangiogram, the
biliary tree is not visualized to the same extent, likely
secondary to injection of contrast via the more medially located
T-tube, with the tip appearing to be located within the most
medially contained leak.
CT ABDOMEN W/CONTRAST [**2124-11-28**] 1:44 PM
IMPRESSION:
1) Compared to the previous exam of [**2124-11-19**], there is a new
bilious fluid collection tracking along the undersurface of the
liver parenchyma, which drains into a larger pocket of fluid
within the right flank. As described above, this fluid
collection was subsequently drained and a 10 French drainage
catheter was placed.
2) Interval increase in the amount of abdominal ascites. A
diagnostic paracentesis was also performed, as discussed above.
The fluid was subsequently sent for a bilirubin level.
3) A triphasic scan through the liver demonstrates patent
hepatic arteries, portal veins and hepatic veins.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2124-11-21**] 8:15 AM
IMPRESSION:
1). Patent intrahepatic vasculature, as described above.
2). Mild intrahepatic ductal dilatation.
[**2124-11-19**] 10:57 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION
1. Diffuse dilatation of both the large and small bowel. No
transition point is identified, and this is consistent with an
ileus. No free air or bowel wall inflammation is identified. A
metallic density in the left lower quadrant small bowel is
likely surgical suture, clinical correlation recommended.
2. A small-to-moderate amount of ascites which is slightly
increased when compared to previous study.
[**2124-11-8**] 11:34 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: r/o biloma, abscess
IMPRESSION: 1) Small amount of perihepatic fluid and small
right-sided pleural effusion consistent with prior ultrasound.
2) Periportal edema.
3) Patent hepatic vasculature.
4) Small wedge shaped area of hypodensity in the anterior aspect
of the transplant liver which could represent an area of
relative [**Name (NI) 23565**].
T-TUBE CHOLANGIO (POST-OP) [**2124-11-7**]
IMPRESSION:
1) Slow contained leak of contrast extending from the
anastomosis.
2) No evidence of stricturing, obstruction, or intrahepatic
biliary ductal dilatation
[**2124-11-2**] 8:21 AM
US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL
IMPRESSION:
1. Patent hepatic vasculature, as discussed above, with improved
appearance of the hepatic arterial waveforms compared to the
exam of [**2124-11-1**].
2. Persistent perihepatic ascites and right pleural effusion.
DUPLEX DOPP ABD/PEL [**2124-10-31**] 8:35 AM
Status post liver transplant, postoperative day #1;Evaluate
vasculature.
IMPRESSION:
1) Patent hepatic vasculature; Trace perihepatic ascites;
Probable small right pleural effusion.
Brief Hospital Course:
The patient is a 47-year- old male who underwent a living donor
right hepatic lobe
liver transplant on [**2124-10-30**]. The patient subsequently
has developed evidence of hepatic artery stenosis requiring
stenting of the hepatic artery, and
a bile leak demonstrated on cholangiography. On [**2124-11-30**] he
therefore underwent a Revision of Roux-en-Y hepaticojejunostomy
to right anterior hepatic duct, Tru-Cut biopsy of the liver &
oversewing of right posterior hepatic duct.
Hospital course complicated by VRE in infected acsites, treated
, as well as bactermeia/sepsis treated, (see microbiology for
details);
Also has rejection of his transplant which on the last biopsy
prior to DC showed mild inflammation but no longer an acute
rejection.
Medications on Admission:
Had included multivitamins, Actonel 35 mg once
a week, Actigall 500 t.i.d., pancreas one t.i.d., vitamin D four
hundred units once a day, calcium, and Peptamen
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 2 weeks.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection per sliding scale.
4. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Valganciclovir HCl 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Outpatient Lab Work
Labs every Monday and Thursday: CBC, Chem 10, ALT, AST, ALK
Phos, T. [**Name (NI) **], Albumin, PT, PTT, Prograf (Tacrolimus)trough
level.
Fax results to [**Hospital1 18**] Transplant Ctr [**Telephone/Fax (1) 697**]
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
13. Tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO BID (2 times a
day) for 2 doses.
14. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical PRN (as needed).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Living unrelated liver transplant, complicated by biliary
leak, exploratory laparotomy with revision roux-en-y
anastomosis, PTC bile drains.
Liver rejection, treated
VRE in ascites
Discharge Condition:
stable/ fair
Discharge Instructions:
Call transplant office [**Telephone/Fax (1) 673**] if any fevers, chills,
nausea, vomiting, inability to take medicines, abd pain,
increasing jaundice, abdominal pain, lack of drainage from
drains or if bile drain pulls out.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-4**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-10**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-17**] 11:00
Please obtain CBC, Chem 10 AST, ALT, alk phosph, albumin, T.
[**Month/Day/Year **], and Prograf every Monday and Thursday. Please either
come to LMOB basement or go to a local facility to have blood
drawn. Make sure facility faxes the results immediately to
[**Telephone/Fax (1) 697**]
Completed by:[**0-0-0**]
ICD9 Codes: 5715, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4421
} | Medical Text: Admission Date: [**2185-1-2**] Discharge Date: [**2185-1-14**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
hypotension, bacteremia
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known firstname 6164**] is a 36 yo male with h/o DM, HTN, gastroparesis who
has been hospitalized numerous times over the past 2 years for
N/V/D and hypertensive emergencies. He now presents with
typical symptoms of N/V/D and fever. He states he was feeling
well up until midnight of last night. At that time he developed
fever, nausea, vomting, and diarrhea. States yesterday he was
dialyzed without problems. Tolerated PO's yesterday and then
developed these symptoms last night. Pt also noted sore throat,
occasional cough. He denies any SOB, DOE, PND, orthopnea.
Currently he denies any abdominal pain, nausea has improved.
In the ED he was noted to be febrile to 103, tachycardic,
hypertensive, and had a lactate of 4.8. Therefore code sepsis
was initiated. He had a central line placed. Given 8 liters of
IV fluids. However his BP was 230, so he was also given
nifedipine and dilaudid, which got his BP down to 180 then into
the 110-120 range. He was also empirically given levofloxacin,
flagyl, and vancomycin in the ED. Also recieved numerous doses
of dilaudid and anzemet.
Past Medical History:
1. DMI for over 10 years
2. Severe autonomic dysfunction with recurrent hospitalizations
for hypertensive emergencies, gastroparesis, and orthostatic
hypotension
3. ESRD on HD started [**2-18**]
4. History of esophageal erosion, MW tear
5. CAD withh 50% first diagonal stenosis, nl stress in [**11-15**]-CAD
6. Recent admit in late [**Month (only) **] for aspiration vs
community-acquired pneumonia
7. History of port-a-cath related coag neg staph infection, s/p
prolonged course IV vancomycin and replacement of port-a-cath in
[**12-17**]
Social History:
Living situation labile now as he and his girlfriend broke up.
He has five children, ranging in age from 11 to 15. Has limited
finances currently as child support is being taken from his SSDI
checks, so he is having difficulty getting his medications.
Social work is working with him to get him established in
pharmacy program. No tob, EtOH or illicits.
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
T 103(in ED) BP 230/110->111/60 HR 104 RR 23 O2sats 96% RA CVP
12
Gen: Lethargic, young male, falling asleep throughout interview
HEENT: Dry MM, PERRL, EOMI, anicteric, clear OP no exudate
Neck: no JVD
Lungs: CTAB
Heart: Tahcy, no m/r/g
Abd: Soft, NT, ND + BS
Ext: Trace edema
Neuro: A&O times 3, grossly intact
Pertinent Results:
Labs/Imaging
CXR- Right subclavian port-a-cath, left subclavian central line,
no cardiopulmonary process
CT abd scattered/patchy opacities, increased septal lines, sm
b/l pleural effusions, liver/GB/spleen/kidneys/adrenals all
normal, diffuse stranding indicative of anasarca, sm ascites
[**2185-1-2**] 06:20AM BLOOD WBC-6.7 RBC-4.72 Hgb-12.2* Hct-37.6*
MCV-80* MCH-25.9* MCHC-32.5 RDW-19.7* Plt Ct-129*
[**2185-1-14**] 04:15AM BLOOD WBC-5.4 RBC-3.89* Hgb-9.6* Hct-30.8*
MCV-79* MCH-24.8* MCHC-31.3 RDW-19.7* Plt Ct-221
[**2185-1-2**] 06:20AM BLOOD Neuts-92.0* Bands-0 Lymphs-5.8*
Monos-0.7* Eos-1.2 Baso-0.3
[**2185-1-2**] 11:35AM BLOOD Neuts-68 Bands-31* Lymphs-1* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2185-1-3**] 04:30AM BLOOD Neuts-60 Bands-33* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2185-1-4**] 04:36AM BLOOD Neuts-78* Bands-10* Lymphs-3* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-2*
[**2185-1-5**] 04:06AM BLOOD Neuts-76* Bands-13* Lymphs-4* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-1-6**] 04:19AM BLOOD Neuts-94.0* Bands-0 Lymphs-4.7*
Monos-0.9* Eos-0.1 Baso-0.3
[**2185-1-7**] 06:00AM BLOOD Neuts-92* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* Plasma-2*
[**2185-1-8**] 05:25AM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-8 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* Plasma-2*
[**2185-1-10**] 03:38AM BLOOD Neuts-76.9* Lymphs-14.5* Monos-8.5
Eos-0.1 Baso-0.1
[**2185-1-2**] 06:20AM BLOOD Plt Smr-LOW Plt Ct-129*
[**2185-1-3**] 04:30AM BLOOD PT-16.7* PTT-57.0* INR(PT)-1.9
[**2185-1-3**] 08:15AM BLOOD Plt Smr-LOW Plt Ct-92*
[**2185-1-3**] 01:50PM BLOOD Plt Ct-83*
[**2185-1-9**] 05:39AM BLOOD Plt Ct-126*
[**2185-1-10**] 03:38AM BLOOD Plt Ct-202#
[**2185-1-11**] 06:50AM BLOOD PT-13.2 PTT-32.5 INR(PT)-1.2
[**2185-1-14**] 04:15AM BLOOD Plt Ct-221
[**2185-1-3**] 08:15AM BLOOD Fibrino-262 D-Dimer->[**Numeric Identifier 961**]*
[**2185-1-3**] 08:15AM BLOOD FDP-320-640*
[**2185-1-3**] 01:50PM BLOOD Fibrino-320
[**2185-1-3**] 01:50PM BLOOD FDP-160-320*
[**2185-1-4**] 04:36AM BLOOD Fibrino-400
[**2185-1-5**] 04:06AM BLOOD Fibrino-514*
[**2185-1-2**] 06:20AM BLOOD Glucose-226* UreaN-19 Creat-5.8* Na-142
K-3.3 Cl-97 HCO3-26 AnGap-22*
[**2185-1-14**] 04:15AM BLOOD Glucose-134* UreaN-28* Creat-5.5*# Na-136
K-3.6 Cl-98 HCO3-28 AnGap-14
[**2185-1-2**] 06:20AM BLOOD ALT-5 AST-14 LD(LDH)-230 CK(CPK)-87
AlkPhos-104 Amylase-85 TotBili-0.4
[**2185-1-3**] 08:15AM BLOOD LD(LDH)-218 TotBili-0.5
[**2185-1-3**] 10:55AM BLOOD ALT-11 AST-30 AlkPhos-89 Amylase-43
TotBili-0.4
[**2185-1-6**] 04:19AM BLOOD ALT-33 AST-20 AlkPhos-191* TotBili-0.7
[**2185-1-7**] 06:00AM BLOOD ALT-16 AST-15 CK(CPK)-21* AlkPhos-145*
TotBili-0.4
[**2185-1-7**] 03:50PM BLOOD CK(CPK)-22*
[**2185-1-2**] 06:20AM BLOOD Lipase-126*
[**2185-1-3**] 10:55AM BLOOD Lipase-13
[**2185-1-6**] 04:19AM BLOOD GGT-56
[**2185-1-2**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.25*
[**2185-1-7**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2185-1-7**] 03:50PM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2185-1-8**] 05:25AM BLOOD CK-MB-2 cTropnT-0.21*
[**2185-1-2**] 06:20AM BLOOD Cortsol-41.0*
[**2185-1-3**] 09:40AM BLOOD Cortsol-29.0*
[**2185-1-3**] 12:05PM BLOOD Cortsol-46.3*
[**2185-1-3**] 12:50PM BLOOD Cortsol-51.0*
[**2185-1-2**] 06:20AM BLOOD CRP-2.6
[**2185-1-3**] 04:30AM BLOOD Vanco-29.4*
[**2185-1-3**] 10:55AM BLOOD Vanco-26.2*
[**2185-1-3**] 10:45PM BLOOD Vanco-22.6*
[**2185-1-4**] 04:36AM BLOOD Vanco-24.0*
[**2185-1-9**] 05:39AM BLOOD Vanco-24.2*
[**2185-1-10**] 03:38AM BLOOD Vanco-21.1*
[**2185-1-11**] 08:00AM BLOOD Vanco-17.4*
[**2185-1-2**] 06:28AM BLOOD Lactate-4.8*
[**2185-1-2**] 07:38AM BLOOD Lactate-3.9*
[**2185-1-2**] 08:31AM BLOOD Lactate-7.0*
[**2185-1-2**] 05:52PM BLOOD Lactate-4.0*
[**2185-1-5**] 12:31PM BLOOD Lactate-1.1
[**2185-1-10**] 01:11PM BLOOD Lactate-1.9
Brief Hospital Course:
1. Fever: Pt with an elevated temp, tahcycardia, relative
hypotension and elevated lactate therefore put into code sepsis
protocol. Also came back with significant bandemia. Possible
sources for sepsis include line infection, cdiff, influenza.
CXR showed no evidence of pneumonia or opacities. CT abd/pelvis
showed no obvious infectious source. Blood cultures drawn on
admission grew out 4/4 bottles of pan-sensitive Klebsiella. He
was given aggressive IVF (13 L). He was initially started on
Meropenem/Vancomycin; this was changed to ceftriaxone once
sensitivities were performed, and vancomycin was discontinued.
He continued to defervesce, and WBC improved. He was initially
placed on vasopressors (Levophed, vasopressin), but these were
weaned off when possible. He failed a cortisol stimulation test
and was placed on hydrocortisone/fludricortisone. Source of
infection was thought to be his port-a-cath, and this was
removed. Surveillance blood cultures remained negative. Sputum
was negative for Influenza, and stool was negative for C.
difficile. Lactate levels were followed and improved with
treatment. After transfer to the floor, he devoloped hypoxia,
hypotension, perhaps [**3-17**] worsening pna. Antibiotics were
changed to Vanco/ceftazidime/flagyl to more broadly cover. The
flagyl was discontinued and the patient was going to be treated
with a 14 day course of vanco and ceftaz. Unfortanately, the
patient eloped from the hospital on day 12 of his antibiotic
course.
2. Hypercarbic respiratory failure: Pt was initially intubated
due to fatigue. He also had signs of pulmonary edema on CXR
(likely [**3-17**] IVF received as part of sepsis protocol/treatment).
Fluid status was managed with hemodialysis. After pressors were
weaned, he was transitioned to pressure support and ultimately
extubated on [**1-5**]. He was initially placed on NC O2, and this
was weaned as possible. After transfer to the floor, he
developed hypoxia with an increasing O2 requirement, CXR showing
worsening failure and ?PNA. He was transferred back to ICU; CTA
was negative for PE, TTE was unchanged. Hypoxia improved with
dialysis and was most likely secondary to volume overload with
superimposed worsening pna (VAP, nosocomial, ?aspiration from
extubation). HD was continued, and abx coverage was expanded to
vanco/ceftazidime/flagyl. He had also been hypotensive in the
setting of this hypoxia, started on levophed (which was
ultimately weaned); this was perhaps [**3-17**] pna/bacteremia,
restarting of antihypertensives. The patient improved and was
oxygenating well on RA on the medical floor.
3. N/V/D: Antiemetics were continued as necessary; he had tube
feeds/NGT while intubated. PO (diabetic, renal) diet was
commenced after extubation.
4. Anion gap: Pt has had this on past admissions. Likely
secondary to lactate and uremia. Gap corrected after fluids.
5. ESRD: Sevalemer was initially held secondary to low
phosphate but restarted with PO diet. Renal was consulted, and
hemodialysis was continued in-house. He was given
Epogen/ferrlecit as per renal. US of fistula was performed;
fistula was thought to be patent, with a likely benign fluid
collection. Sevalemer and ampogel were restarted prior to the
patient leaving the hospital.
6. DM: While in the unit, he was maintained on a humalog scale
and was transitioned to his outpatient regimen ([**Hospital1 **] lantus).
His sugars were running high in the 200-300's and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was called, but unfortunatly, the patient left prior to
being seen.
7. HTN: Patient with hypertensive urgency on admission. BP
went from the 230's to 120's after getting nifedipine and
dilaudid. Blood pressure was low upon initiation of MUST
protocol, and he was placed on pressors as above.
Antihypertensives were restarted as hemodynamic status improved.
8. Thrombocytopenia: Patient developed low platelets following
initial aggressive fluid resuscitation. This was initially
thought to be secondary to dilution. This persisted, however,
and other etiologies were considered. HIT was sent, and heparin
products were held (pt had been on SQ heparin). Medications
were reviewed (he had received Vancomycin and meropenem, both of
which could cause this). Cause was likely multifactorial,
secondary to sepsis, s/p pressors, medications effect.
9. Gastroparesis: Reglan was continued when pt was taking PO's.
10. Positive PPD: He has history of positive PPD. No lesions
on CXR, however since he is on transplant list being treated
with isoniazide and pyridoxine. These were held on admission to
prevent hepatotoxicity but were restarted later during the
admission.
11. Disposition: He was transitioned from the MICU to the floor
and continued to improve. Unfortunatly, the patient eloped the
hospital prior to being officially discharged. Security was
called but could not locate the patient. I am attempting to
contact the patient with a follow up appointment to have a new
port placed by general surgery.
Medications on Admission:
Clonidine 0.3 mg/24 hr qweek (sun), Aspirin 325 mg qday, Insulin
Glargine 6 units [**Hospital1 **], Nifedipine 60 mg qday, Pantoprazole 40 mg
qday, Isoniazid 300 mg qday, Pyridoxine 50 mg qday, Sevelamer
800 mg tid, Metoprolol 50 mg [**Hospital1 **], Reglan 10 mg qid, Clonidine
0.4 mg tid, Insulin Lispro per scale
Discharge Medications:
Patient eloped
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Sepsis
Discharge Condition:
patient eloped
Discharge Instructions:
Patient eloped
Followup Instructions:
Patient eloped; I will attempt to contact the patient to set up
an appointment with his PCP and with general surgery (for a
PORT)
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
ICD9 Codes: 486, 2762, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4422
} | Medical Text: Admission Date: [**2191-1-15**] Discharge Date: [**2191-1-24**]
Date of Birth: [**2135-3-24**] Sex: F
Service: GEN MED
The patient is a 55-year-old Hispanic female that is mostly
Spanish-speaking who is a smoker who is transferred from the
outside hospital for respiratory failure. The patient
originally presented with one week of dry, nonproductive
cough, high fevers and chills and productive shortness of
breath. She was admitted to the outside hospital on [**2191-1-9**]
with reportedly influenza A positivity. The patient
developed hypoxia, hypercapnia and respiratory failure with
bilateral infiltrates noted on chest x-ray with the
accompaniment of orthopnea, diffuse wheezing and tachypnea. .
The patient was subsequently intubated on [**2191-1-11**]. She then
became hypertensive with cephalic blood pressures 140s/210s
and developed oliguric acute renal failure at the outside
hospital. The patient was started on broad spectrum
antibiotics including Vancomycin, Levaquin, Amantadine,
Fluconazole, bronchodilators and Lasix. She was diuresed,
managed on antibiotics and then transferred to the [**Hospital1 1444**] [**Hospital Unit Name 153**] on [**1-15**] for further
management.
The patient was managed in the [**Hospital Unit Name 153**], extubated on [**2191-1-19**] and
transferred to the Floor on [**2191-1-21**]. Upon her transfer to
the Medicine Floor, the patient denied any chest pain,
shortness of breath, nausea, vomiting, emesis, fevers or
chills. She had no breathing problems and stated that she
was breathing comfortably.
PAST MEDICAL HISTORY: Otherwise significant for
hyperlipidemia and history of cervical cancer greater than 10
years ago status post total abdominal hysterectomy and
chemotherapy.
MEDICATIONS ON TRANSFER: Included Ceftriaxone 1 gram q 24
hour, Methylprednisolone 40 mg IV q 6 hours, Salmeterol
Diskus inhaler q 12 hours, Fluticasone 110 mcg four puffs
[**Hospital1 **], Albuterol inhaler q four hour, Albuterol nebulizers prn,
Ipratropium bromide inhalers q every four to six hours prn,
Ipratropium MDI two puffs inhaled qid, insulin sliding scale,
Pantoprazole 40 mg one po q 24 hours, Acetaminophen prn,
Heparin 5000 units q 8 hours, Colace 100 po bid, Senna one
tab po bid and Bisacodyl 10 mg po qd prn.
PHYSICAL EXAMINATION: Temperature 98.9, blood pressure
136/70, heart rate 74, respiratory rate 18, satting at 94% on
6 liters by nasal cannula. The patient's exam, generally she
is a middle-aged female sitting in a chair in no acute
distress. The skin is clean, dry and intact. HEENT is
normocephalic, atraumatic, extraocular movements are intact.
Oropharynx is clear with moist mucous membranes. Neck is
supple with no jugular venous distention. Heart is regular
rate and rhythm with no murmurs, rubs or gallops, normal S1,
S2. Lungs are clear with minimal expiratory bases diffusely
and no crackles noted. Abdomen is soft, nontender with
normal active bowel sounds. Extremities: Without clubbing,
cyanosis or edema, 2+ pedal pulses. Neuro exam: Cranial
nerves II through XII are intact. Strength is [**4-27**] and
symmetric. Toes are downgoing. Reflexes are symmetric
throughout. The patient is alert and oriented times 3. She
is conversant, answers questions appropriately in Spanish,
follows two step commands.
DATA ON TRANSFER: White count is 26.5 from a high of 32.7,
hematocrit is 27.3 and platelet count is 641. Her chem 10 is
as follows: Sodium 143, potassium 4.4, chloride 105,
bicarbonate 30, BUN 36, creatinine 1.2 (1.2 is the patient's
baseline creatinine), glucose 137, calcium is 8.3, magnesium
is 2.2 and phosphate is 3.7.
Abdominal ultrasound is significant for gallbladder sludge
with no evidence of cholecystitis and otherwise exam is
within normal limits. Micro: Blood cultures from [**1-16**], 1/29
times four, no growth to date. C. difficile is negative
times two.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory failure: Likely consistent with underlying
previously undiagnosed chronic obstructive pulmonary disease
which was exacerbated by influenza, infection. The patient
had a negative CTA at the outside hospital. The patient was
continued on Levofloxacin for atypical community-acquired
pneumonia as well as Amantadine and Vancomycin which was
discontinued on [**1-18**]. The patient was initially continued on
IV Solu-Medrol for chronic obstructive pulmonary disease
exacerbation which was started on [**1-15**]. This was changed to
prednisone at 60 mg, one po qd. . The patient was to continue
a very slow prednisone taper outpatient otherwise patient
continued on nebulizer MDIs and by date of discharge, the
patient was free of nebulizer use and was maintained on MDIs.
The patient quit smoking approximately three weeks prior to
admission and was able to abstain throughout her hospital
admission without the need for a nicotine patch.
2. Infectious Disease: The patient had a urinary tract
infection which was resistant to E. coli with sensitivity to
Cephalosporin and Nitrofurantoin. The patient was not given
Nitrofurantoin given that her creatinine clearance was less
than 60.
The patient had a negative penicillin skin test on [**2191-1-17**]
and was started on Ceftriaxone. The patient also had
leukocytosis which was trending down by the date of discharge
and returned to a low of 23.3 and this was felt secondary to
steroid use. The patient received her last dose of
Ceftriaxone to complete a seven day course prior to
discharge. The patient's stool remained negative for C. diff
times two. Blood cultures remained no growth to date by date
of discharge. The patient was maintained on contact
precautions secondary to resistant urinary tract infection.
3. Elevated alkaline phosphatase and GGT: The patient has a
very benign abdominal exam. It is felt that this is related
likely to acute illness or medications including Ceftriaxone.
The patient's abdominal exam was consistent with gallbladder
sludge with evidence of cholecystitis and otherwise exam was
within normal limits and reassuring. Her liver function
tests trended down by date of discharge and should be fold
outpatient to insure they are solving to normal.
4. Renal: Acute renal failure again felt secondary to ATN
secondary to dye at the outside hospital or AIN due to
previous medications including Azithromycin, Fluconazole and
gentamicin. The patient's creatinine remains stable at 1.2.
The patient had very good urine output upon discontinuation
of Foley catheter.
5. Mental status: The patient was previously agitated,
possibly secondary to ICU/steroid psychosis infection or
foreign-language barrier. She was resistant to help and
Ativan prn however by the time of transfer to Medicine, the
patient was very calm, was alert and oriented times 3,
conversant and entirely appropriate.
6. Cardiovascular: The patient was diuresed initially
secondary to fluid overload and echo down to 126 was within
normal limits with an ejection fraction of greater than 60%,
no evidence of regurgitation, no other valvular abnormalities
and no evidence of wall motion abnormality noted. The
patient's lung remained clear. The fluid goal for her was to
remain euvolemic which she did throughout her
hospitalization. By the time of discharge, the patient was
satting 96% to 98% on room air with no evidence of fluid
overload. Her lungs remained clear. She had no jugular
venous distention.
7. Anemia: The patient's iron studies in the past have been
consistent with anemia of chronic discharge but her iron and
TIBC are also less than 100%. Her hematocrit throughout her
hospitalization remained stable and increased from 27.3 to
30.3.
8. History of deep venous thromboses: Lower extremity
Dopplers were negative. CT Scan was negative at the outside
hospital. The patient was maintained on subcutaneous Heparin
5000 units q 8 hours.
9. FEN: The patient was advanced from clears to cardiac
diet. She was Reglan initially but tolerated a regular diet
without use of Reglan. Additionally her hyperglycemia is
secondary to steroid use. The patient was continued on a
Regular insulin sliding scale. Her blood sugars ranged from
130s to 190s.
10. Prophylaxis: The patient was maintained on proton pump
inhibitors of q Heparin, bowel regimen and aspiration
precautions.
11. The patient has a right subclavian from outside hospital
which was discontinued prior to discharge. The patient is a
full code. Her communication was with her daughters.
The patient was discharged home on [**2191-1-24**]. The
patient's discharge condition is stable. She is stable on
room air. She is able to ambulate without desatting or
development of tachycardia. The patient is tolerating
cardiac diet, is alert and oriented times 3 and has had no
evidence of hypovolemia. The patient is recommended to
follow up with Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 15674**] on [**2191-2-8**] at
9:15 am. The patient should also follow up with her
pulmonologist within one month.
DISCHARGE MEDICATIONS AT DISCHARGE:
1. Salmeterol 50 mcg Diskus one puff q 12 hours.
2. Fluticasone 110 mcg four puffs [**Hospital1 **].
3. Ipratropium MDIs, two puffs qid.
4. Albuterol inhalers, two puffs q 6 hours.
5. Pantoprazole 40 mg one po qd.
6. Prednisone taper as follows: 60 mg one po q am for three
days then 50 mg one po q am for five days then 40 mg one po q
am for five days then 30 mg, one po q am for five days then
20 mg one po q am for five days then 10 mg on q am for five
days then 7.5 mg, one po q am for five days then 5 mg one po
q am for 10 days then 2.5 mg one po q am for 10 days then 2
mg, one po q am for 10 days then 1 mg one po q am for 10 days
and then stop.
DISCHARGE DIAGNOSES:
1. Respiratory failure secondary to chronic obstructive
pulmonary disease and influenza infection.
2. Urinary tract infection.
3. Acute renal failure.
4. Altered mental status.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2191-1-24**] 11:06
T: [**2191-1-24**] 19:48
JOB#: [**Job Number 53200**]
ICD9 Codes: 5849, 5990, 3051, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4423
} | Medical Text: Admission Date: [**2170-3-7**] Discharge Date: [**2170-3-14**]
Service: MEDICINE
Allergies:
Zestril / Hydrochlorothiazide
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain and loose stools
Major Surgical or Invasive Procedure:
none
History of Present Illness:
MICU GREEN JAR ADMIT NOTE
.
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] [**Hospital3 **], [**Apartment Address(1) 71669**] [**Hospital1 8**]
[**Telephone/Fax (1) 7976**]
ORTHO: [**Location (un) **]
.
CC: abdominal pain, hypotension
.
HPI: [**Age over 90 **] y/o female from [**Hospital3 2558**] complaining of abdominal
pain and having loose stools, found with coffee ground emesis,
and hypotensive with SBP in the 60's. Recently on amoxacillin
and was on clindamycin after last discharge. Poor PO intake
recently.
.
In ED, NG tube attempt failed and patient vomited coffee
grounds, which was guaiac positive. Stool was liquid yellow and
guaiac negative. Afebrile axillary. Hypotensive to 90's at the
lowest. Difficult access, but Left IJ placed after multiple
failed subclavian attempts. Labs showed Lactate 7.6, Cr 3.0, and
AG of 24. CT of abdomen showed pancolitis. Given half dose of IV
Vanco.
.
Past Medical History:
PMH:
HTN
DM 2
CAD
NSTEMI in the setting of surgery
Recent echocardiogram with 30% ejection fraction with moderate
global left ventricular systolic dysfunction, moderate mitral
regurgitation, moderate tricuspid regurgitation, and moderate
pulmonary hypertension
Recent Pneumonia -Question LLL on previous admission
Alzheimers dementia
Arthritis
s/p ORIF of left intertrochanteric fracture
Diverticulosis
Colon polyps
Anal resection
IBS
Social History:
SOCIAL HISTORY: Lives at [**Hospital6 71670**] Home.
Family History:
non-contributory
Physical Exam:
Thin, elderly female
T 96.4 axillary HR 93 BP 134/58 RR 32 SAT 93% RA 100% 2L
SKIN: dry, warm
HEENT: Pupils 5mm and fixed
NECK: No JVP elevation, left IJ in place
CHEST: No rhonchi
HEART: Regular
BACK: Mild spot rash in distribution of dermatome on left abd
wall
ABD: Distended, tense, no bowel sounds, tender with rebound
EXT: No edema, warm
NEURO: Moaning. Answering questions but not consistantly
responsive. Able to hold both arms up against gravity.
Pertinent Results:
LABS: MCV 93
39.3>--<420
....46.6
.
[**Age over 90 **]|113|64 AGap=29
-----------<152
5.0|17 |3.0
.
CK: 122 MB: 3 Trop-T: 0.06
.
Ca: 9.3 Mg: 2.6 P: 6.0
ALT: 12 AST: 27 AP: 102 Tbili: 0.3
[**Doctor First Name **]: 37 Lip: 13
.
PT: 12.6 PTT: 21.7 INR: 1.1
.
Lactate:7.6
.
EKG: NSR at 90. TWI in inferior leads. ST depressions in lateral
limb leads and V2/V3. TW flattening V3-V6.
.
CHEST/ABD CT: Pancoloitis
.
Brief Hospital Course:
A/P: [**Age over 90 **] y/o female with hypotension, coffee ground emesis,
diarrhea, hypernatremia, elevated lactate, anion gap lactic
acidodis, renal failure, and pancolitis.
.
C diff colitis/sepsis - patient was admitted to the MICU
hypotensive and found to be in septic shock from c diff colitis.
A central line was placed. She was treated with IV flagyl. Upon
discussion with her HCP, it was decided to change goals of care
to comfort. She was continued on her antibiotics and placed on a
dilaudid drip for pain. transferred to the floor as CMO status.
[**3-13**] antibiotics were stopped, switched to morphine drip for
better titration.
[**3-14**] deceased. TOD 11:40am
Medications on Admission:
MEDICATIONS:
Docusate 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Magnesium Hydroxide 30 mL q6h
Oxycodone 5 mg q4hours prn
Metoprolol 12.5 mg [**Hospital1 **]
Aspirin 325 mg daily
Atorvastatin 20 mg daily
Losartan 25 mg daily (recently stopped)
Remeron 30 mg qhs
Multivitamin daily
Caltrate and Vit D [**Hospital1 **]
Amoxacillin
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
.
Followup Instructions:
.
ICD9 Codes: 0389, 2760, 5849, 4589, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4424
} | Medical Text: Admission Date: [**2188-4-21**] [**Month/Day/Year **] Date: [**2188-4-26**]
Date of Birth: [**2107-11-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
Left hip open reduction and fixation [**2188-4-23**]
History of Present Illness:
80 F with history of Childs class B cirhosis (SBP, variceal
bleed, ascites), Hep C, ESRD on HD (tunnel line, HD started few
mo ago, has fistula in left arm), CAD (sp 2 stents in the past),
DM2 on insulin, who presents to hospital for hip fracture.
She was in her usual state of health until yesterday when she
was sitting in a chair and fell. She reported to the ED where
she was found to have left subgaleal hematoma, right 7th rib
frx, left proximal femur fracture. There was initial question of
black stool, however on repeat exam stool was brown and GI did
not feel urgent endosopy was warranted.
.
She was transfered to the Trauma ICU service for close
observation until surgery. Ortho, Liver, ACS, Nephrology are all
consulting. She was intially planned to go to the OR today,
however, her electrolytes were off and she needs HD prior to OR.
Risks of surgery have been explained to patient's family at
legnth and they are in agreement with plan to proceed with
surgery for fixation of hip fx.
.
On arrival to the MICU, pt reports she has left hip pain but
otherwise denies any other symptoms. No confusion, no weakness
of arms or legs, does have extensive bruising on her head from
fall.
.
Family meeting held with daughter in law and son. They are aware
of how sick their mother is and understand the high mortality
risk of the surgery, but they still request surgery. Code status
is DNR ("not okay to rescusitate if no heart beat or pulse") but
okay to intubate.
Past Medical History:
CAD- stents in [**2180**]
Hep C cirhosis- CHILD B - complicated with esophageal varices sp
banding, SBP/ascites in [**11/2187**]
ESRD on HD (possible from Hep C, had attempted renal bx)
GERD
Anemia
Uterine polyps
Social History:
No drugs, pts family feels she got Hep C in the hospital setting
while in the [**Location (un) 3156**]. Lives alone in apartment. Has 2 children,
4 grandchildren.
Family History:
Mother with DM2 and MI.
Physical Exam:
Physical Exam on admission:
Vitals: T: 98, HR 62, BP 122/47, RR 18, 96% on 2L. 150cc uo.
General: Alert, oriented, jaundice, bruising on head,
chronically ill appearing
HEENT: Sclera icteric, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
left sternal border
Lungs: anteriorly pt had no crackles bilaterally
Abdomen: soft, mild ascites present
GU: foley
Ext: warm, 2+ pulses, no pedal edema
Neuro: [**6-7**] strengh throughout
Physical Exam on [**Month/Day (1) **]:
VS - Tm 99.0 Tc 98.3 BP 138/70, HR 77, R 18, O2-sat 100% 3L
(Nasal cannula noted to be over patient's forehead)
GENERAL - elderly woman, laying in bed in NAD, alert and very
talkative with Russian interpreter
HEENT - Promient bruising around eyes, with hematoma over left
forehead, left eye held slightly closed [**3-6**] swelling, pupils
equally round and tracking spontaneously, dry MM
NECK - supple, prominent carotid upstroke
LUNGS - Nonlabored, speaking quickly in full sentences, anterior
auscultation CTAB
HEART - RRR, II/VI holosystolic murmur LSB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, left leg with lesion noted by MICU and ACS
dressed, left hip dressing intact. Moving left toes toes and
ankle. Poor DP on left but foot warm with good cap refill.
Moving all other extremities. No edema
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - Alert, able to relay events leading to fall, symmetric
face except left eye droop due to swelling, symmetric tongue,
eyes tracking appropriately, pupils equally round, moving all
extremities.
Pertinent Results:
Labs on admission:
[**2188-4-21**] 04:00PM BLOOD WBC-4.9 RBC-3.20* Hgb-9.2* Hct-29.8*
MCV-93# MCH-28.9# MCHC-31.0 RDW-15.3 Plt Ct-107*
[**2188-4-21**] 04:00PM BLOOD Neuts-71.9* Lymphs-20.5 Monos-4.6 Eos-2.5
Baso-0.5
[**2188-4-21**] 09:38PM BLOOD PT-12.2 PTT-31.5 INR(PT)-1.1
[**2188-4-21**] 04:00PM BLOOD Glucose-220* UreaN-60* Creat-3.8*#
Na-129* K-5.1 Cl-96 HCO3-19* AnGap-19
[**2188-4-21**] 04:00PM BLOOD ALT-32 AST-51* AlkPhos-138* TotBili-0.5
[**2188-4-21**] 04:00PM BLOOD Lipase-63*
[**2188-4-21**] 04:00PM BLOOD cTropnT-0.04*
[**2188-4-22**] 04:00PM BLOOD cTropnT-0.03*
[**2188-4-21**] 04:00PM BLOOD Albumin-2.8* Calcium-7.8* Phos-6.8*#
Mg-2.1
[**2188-4-22**] 04:00PM BLOOD AFP-2.6
Labs on [**Month/Day/Year **]:
[**2188-4-25**] 07:31AM BLOOD WBC-4.8 RBC-2.69* Hgb-7.8* Hct-26.1*
MCV-97 MCH-29.1 MCHC-29.9* RDW-16.1* Plt Ct-85*
[**2188-4-25**] 07:31AM BLOOD PT-12.2 PTT-30.3 INR(PT)-1.1
[**2188-4-25**] 07:31AM BLOOD Glucose-167* UreaN-38* Creat-3.3*# Na-135
K-4.1 Cl-97 HCO3-29 AnGap-13
[**2188-4-25**] 07:31AM BLOOD ALT-22 AST-44* LD(LDH)-188 AlkPhos-80
TotBili-1.1
[**2188-4-25**] 07:31AM BLOOD Calcium-7.7* Phos-5.3* Mg-2.1
Imaging:
CT C-spine [**2188-4-21**]: Mild spondylolistheses seen at C3-C4 and
C4-C5, which could be seen with substantial degenerative changes
including facet joint degenerative changes. However, correlation
with physical findings is recommended regarding any potential
concern for ligamentous injury. Hemorrhage in the paranasal
sinuses which could be seen in the setting of fractures that are
occult or not imaged on this study.
CT Head [**2188-4-21**]: 1. Large left frontal subgaleal hematoma,
including hemorrhage among the visualized paranasal sinuses,
which may reflect bony injury which is not imaged. Although
there is no definite fracture, slight irregularity of the partly
visualized nasal bones could reflect an incompletely imaged
fracture site.
2. No evidence of acute intracranial injury.
3. Slight increase in largely calcified meningioma along the
right frontal
convexity.
4. New small lacunar infarcts since the remote prior
examination.
CT Torso [**2188-4-21**]: 1. Non-displaced fracture of the proximal left
femur superimposed on chronic abnormalities.
2. Mildly displaced right seventh rib fracture with additional
rib fractures that appear more likely subacute or older although
more recent non-displaced fractures are difficult to entirely
exclude.
3. Large quantity of ascites which is of low density suggesting
simple fluid. This is suspected to reflect underlying liver
disease,noting slightly irregular contour to the liver and mild
splenomegaly. However, other etiologies including malignancy are
not entirely excluded, although no nodularity or masses are
noted.
4. Widespread vascular disease.
Echo [**4-22**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF 75%). A mild
mid-cavity gradient is identified. 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. There is no mitral valve prolapse. There is
severe mitral annular calcification. There is a minimally
increased gradient consistent with trivial mitral stenosis. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Carotid US [**4-22**]:
IMPRESSION: There is plaque in the distal common carotid
arteries and at the bifurcation extending into the internal and
external carotid arteries. However, no significant stenoses on
either side. Flow in the vertebrals is prograde.
RUQ US with dopplers [**4-22**]:
1. Extensive ascites.
2. Nodular contour to the liver and shrunken appearance
consistent with
cirrhosis. Splenomegaly.
3. Limited Doppler examination with patent main portal vein and
main hepatic artery.
CXR [**4-24**]:
There are low lung volumes. Right central catheter tip is in the
upper right atrium. There is no pneumothorax or pleural
effusion. There is mild vascular congestion. There are small
bilateral pleural effusions. Again noted is calcification of the
mitral annulus.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Mrs [**Known lastname 43842**] is an 80 F with history of Childs class B
cirhosis (SBP, variceal bleed, ascites), Hep C, ESRD on HD, CAD
s/p 2 stents, DM2 on insulin who was evaluated in the [**Hospital1 18**] ED
as a trauma activation, with the following injuries identified:
left subgaleal hematoma, right 7th rib fracture, left
subtrochanteric fracture. She was then admitted to the TICU for
further evaluation and management, before being transferred to
the MICU for close monitoring prior to her left ORIF by ortho on
[**4-23**]. She tolerated the surgery well and was transferred to the
medical floor on [**2188-4-24**].
ACTIVE PROBLEMS
# Hip fracture: Patient underwent ORIF on [**4-23**]. She was extremly
high risk given her underlying medical comorbidities (including
Childs class B cirrhosis, ESRD, cardiac histoey and diabetes).
She tolerated the procedure well. She was kept on dilaudid and
IV tylenol with good pain control in the ICU. On the floor, she
was transitioned to tramadol and standing low dose tylenol. Due
to her ESRD, patient was not on lovenox for DVT ppx, but should
continue on heparin 5000 SQ tid at least until seen by
orthopedics on followup in two weeks.
# Mechanical Fall: After obtaining add'l history, MICU team felt
that the fall was mechanical in nature. Abbreviated syncope
workup was normal with flat troponins, unremarkable TTE, no
significant carotid stenosis and no evidence of infection on CXR
and blood cx. Pt was discharged to acute rehab in good
condition.
# Left shin wound: Appears to be related to fall. Noted by MICU
team on day of tranfer out of untit. She was evaluated by ACS
and orthopedics who felt there was nothing to do other than
wound care.
CHRONIC PROBLEMS
# Hep C Cirrhosis: Childs class B. Decompensated with history of
ascites, variceal bleed s/p banding and hospitalization for SBP.
Patient was afebrile with a soft belly and no clinically
signficant ascites. Stool was brown. Banding apparently done at
[**Hospital3 2005**]. After speaking with liver team, it was decided
to treat patient with ciprofloxacin for SBP prophylaxis and
nadolol for varices.
# HTN: Patient on home regimen of metoprolol succinate 100
daily, nifedipine ER 90mg daily, and HCTZ 25mg daily. Patient
started on metoprolol tartrate 100 [**Hospital1 **] in MICU. SBP's ran in the
90's to 110's, so HCTZ and nifedipine were held in the ICU.
HCTZ, metoprolol were not continued prior to [**Hospital1 **]. She was
discharged on home nifedipine and nadolol.
# ESRD on dialysis: Etiology thought to be due to recent
hospitalizations for SBP and variceal bleeds. Received HD prior
to surgery per renal recs and again on [**2188-4-26**]. She was started
on sevelamer 1600 tid, and continued CaCO3, and vitamin D.
Glyburide, HCTZ, and NSAIDS were discontinued.
# DM: On lantus 10 and glyburide 2.5 at home. HISS was started
in MICU. Patient was placed back on home lantus on the floor.
Glyburide was not continued on [**Month/Day/Year **] due to ESRD.
# Rib fracture: Controlled pain control as above.
# Hx of CAD: Continued ASA and metoprolol.
# Depression: Continued sertraline 25 daily.
MEDICATION CHANGES
STOP alendronate
STOP glyburide
STOP hydrochlorothiazide
STOP ibuprofen
STOP Konsyl
STOP Metoprolol
DECREASE Tylenol to 650mg every 8 hours
INCREASE Tramadol to 50mg every 6 hours as needed for pain
START Heparin 5000u SQ injection three times daily until
otherwise directed by your orthopedic surgeon
START Sevelamer 1600mg three times daily with meals
START Aspirin 81 mg
START Ciprofloxacin 500mg daily
START Nadolol 20mg daily
START Lactulose 15mL titrate to [**3-7**] soft bowel movements daily
TRANSITIONAL ISSUES
-Uptitrate nadalol as needed for BP
-Continue heparin 5000 tid until otherwise directed by
orthopedics
Medications on Admission:
calcium carbonate + vit D600, 1 tab PO BID
colace 100mg PO BID
ferrous sulfate 325mg PO BID
fluticasone nasal spray 50mcg, 2 sprays [**Hospital1 **]
fosamax 70mg PO weekly
glyburide 2.5mg PO BID
HCTZ 25mg PO QOD
Ibuprofen 400mg PO TID PRN pain
Konsyl 6G, 1 pack in 1 cup of water PO QD
Lantus 10USQ QD
Lidoderm patch 5%, [**Hospital1 **]
Nifedipine ER 90mg
omeprazole 20mg PO QD
toprol xl 100mg PO QD
tramadol 25mg PO BID
acetaminophen 650mg PO Q4-6hrs prn pain
vitamin b12 100mg qd
vit d 1000u QD
simvastatin 20mg QD
zoloft 25mg PO QD
[**Hospital1 **] Medications:
1. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
5. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: apply to shoulder.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO once a day.
11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
14. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
17. nadolol 20 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
18. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
mL PO ASDIR: Titrate to [**3-7**] BM daily.
19. nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
[**Month/Day (3) **] Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
[**Location (un) **] Diagnosis:
1. Left hip open reduction and fixation
2. Mechanical fall
3. Decompensated cirrhosis
4. End stage kidney disease
5. Diabetes mellitus
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Location (un) **] Instructions:
Dear Ms. [**Known lastname 43842**],
You were admitted to [**Hospital1 69**]
because you suffered a fall at home and broke your hip and ribs.
You underwent surgery to fix the hip and we gave you medicine to
help control the pain. It is very important for you to undergo
physical therapy to help gain strength back in your legs.
Please note the following changes to your medications:
STOP alendronate
STOP glyburide
STOP hydrochlorothiazide
STOP ibuprofen
STOP Konsyl
STOP Metoprolol
DECREASE Tylenol to 650mg every 8 hours
INCREASE Tramadol to 50mg every 6 hours as needed for pain
START Heparin 5000u SQ injection three times daily until
otherwise directed by your orthopedic surgeon
START Sevelamer 1600mg three times daily with meals
START Aspirin 81 mg
START Ciprofloxacin 500mg daily
START Nadolol 20mg daily
START Lactulose 15mL titrate to [**3-7**] soft bowel movements daily
You will need to follow up with your liver and kidney doctors.
Your rehabilitation hospital will arrange follow up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from their facility. It has
been a pleasure taking care of you.
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2188-5-8**] at 1:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2188-5-8**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***The Liver Dept is working on an appt for you and will call
you at the rehab with your appt. If you dont hear from the
office by Tuesday, please call them at [**Telephone/Fax (1) 2422**] to book.
You will also need to follow up with your primary care doctor
and your kidney doctor. [**First Name (Titles) 2172**] [**Last Name (Titles) 4487**] hospital will help
arrange these appointments.
ICD9 Codes: 5856, 5715, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4425
} | Medical Text: Admission Date: [**2133-8-22**] Discharge Date: [**2133-8-25**]
Date of Birth: [**2084-6-11**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Penicillins / Food Extracts / Latex / Lovenox /
Demerol / Wellbutrin / nsaids
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
epigastric pain and hematemesis x 2
Major Surgical or Invasive Procedure:
PSH: lap RNYGB [**2129**], Lap appy, soft palate surgery, right ankle
surgery
History of Present Illness:
49 y/o man with hx lap roux en y gastric bypass in [**2129**] and hx
marginal ulcer who presents with vomiting blood x 2 since 7pm
[**2133-8-21**]. Per patient, he ate normal breakfast and then had
nausea and decreased appetite during day. He had sudden onset
bright red vomit mixed with clots x 2, associated with light
headedness and left upper quadrant moderate pain. Of note, he
recently completed a course of PO steroids for respiratory
illness. He denies tobacco or NSAID use, and last ETOH 3 weeks
ago.
Past Medical History:
HTN, asthma, GERD, dyslipidemia, PVD, restless leg syndrome,
back pain, shingles, OSA
Social History:
He denies tobacco or recreational drug usage and drinks wine
occasionally (2 to 3 times/wk). He has 1 to 2 cups of coffee
daily and a 12-ounce diet soda occasionally. He is employed as
a real estate broker. He is married and lives with his wife,
age 44. They have no children.
Family History:
Father age 75 with heart disease & hyperlipidemia. Mother age
74 with cancer and asthma. Brother at 48 with hyperlipidemia &
obesity. Twin brother age 48 with obesity. Paternal
grandmother deceased with diabetes.
Physical Exam:
General: Awake, alert, oriented x 3
CV: RRR
Puml: CTAB
Abd: Soft, non-tender, distention hard to assess [**2-26**] size
Extrem: WWP, 2+ radial and DP pulses
Neuro: No focal deficits
Pertinent Results:
[**2133-8-23**] 12:00AM GLUCOSE-83 UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2133-8-23**] 12:00AM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2133-8-23**] 12:00AM WBC-10.0 RBC-3.97* HGB-11.5* HCT-35.3* MCV-89
MCH-29.0 MCHC-32.6 RDW-13.3
[**2133-8-23**] 12:00AM PT-11.4 PTT-33.6 INR(PT)-1.1
Brief Hospital Course:
The patient presented to the [**Hospital1 18**] ED on [**2133-8-22**] with abdominal
pain and hematemesis x 2. Hct on admission was 36, CXR with no
pneumoperitoneum,
CT with remnant thickened (not dilated or fluid filled) - likely
chronic gastritis and duodenitis - consistent with hx of PUD.
Patient was hemodynamically stable and admitted for further
observation
Neuro: The patient was alert and oriented throughout the
hospitalization
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored, hct trended
down to 31.9 on [**2133-8-24**] for a one-time read, all other hct > 33,
with discharge hct 37.5.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: He was initially NPO until EGD completed to confirm
no UGI bleed, after which he was advanced to stage 3, and well
tolerated. Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 4
diet. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Fluticasone 50 2 sprays [**Hospital1 **], FLOVENT 110 [**Hospital1 **], Roxicet prn,
prednisone 5 (finished 5 day course last w), pantoprazole 40
[**Hospital1 **], Carafate prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache
RX *8 HOUR PAIN RELIEVER 650 mg 1 tablet(s) by mouth every six
(6) hours Disp #*64 Tablet Refills:*0
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *Prevacid SoluTab 30 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *Carafate 1 gram/10 mL 10 mL by mouth four times a day Disp
#*1 Bottle Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg/5 mL 5 mL by mouth every six (6) hours
Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain and hematemsis x 2 with EGD showing no active
bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory ?????? Independent.
Discharge Instructions:
You were admitted to the Bariatric Surgery Service at [**Hospital1 1535**] after presenting on [**2133-8-22**] with
abdominal pain and hematemesis x 2.
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, bloody emesis, chest
pain, shortness of breath, severe abdominal pain, severe nausea
or vomiting, severe abdominal bloating, or any other symptoms
which are concerning to you.
Diet: Stay on Stage 4 as tolerated.
Medication Instructions:
Resume your home medications.
1. If you take prescription pain medications, these medications
will make you drowsy and impair your ability to drive a motor
vehicle or operate machinery safely. You MUST refrain from such
activities while taking these medications.
2. You should begin/continue taking a chewable complete
multivitamin with minerals.
3. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
Normal activity as tolerated
Followup Instructions:
Department: BARIATRIC SURGERY
When: [**2133-9-9**] 9:45AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Best Parking: [**Hospital Ward Name 23**] Garage
Weight Loss Surgery Center
[**Hospital1 69**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
[**Location (un) 830**]
[**Location (un) 86**] , [**Telephone/Fax (1) 47701**]
ICD9 Codes: 4019, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4426
} | Medical Text: Admission Date: [**2172-3-24**] Discharge Date: [**2172-4-6**]
Date of Birth: [**2119-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
transfered from OSH for epidural abscess and osteomyelitis
Major Surgical or Invasive Procedure:
L4-L5 laminectomy and epidural abscess debridement [**2172-3-27**]
History of Present Illness:
52 M history of ETOH abuse who is transfered from OSH for
epidural abscess. In late [**Numeric Identifier **] pt was admitted to OSH for 1
week of low back pain radiating to legs, difficulty walking,
fever. He was admitted to the hospital and found to have staph
aureus bacteremia and lumbar discitis. He was initialy treated
with Vancomycin and then tailered therapy to Nafcillin when
sensitivites returned MSSA (last positive culture [**2172-3-9**]). Pt
was hospitalized from late [**2172-2-4**] through [**2172-3-24**] with the
exception of 2 days when he left AMA and then returned. While at
OSH, his hospital coarse was complicated with the following:
1)new diagnosis of ETOH cirhosis, with alb 1.8-2.0, INR 1.6 and
BilliT max in the 2.0-3.0 range, for which he was started on
nadolol, spironolactone and lasix; 2) aspiration pneuomonia in
setting of sedation while on benzos for ETOH withdrawel,
requiring intubation (extubated [**2172-3-7**]) and course of ceftaz and
vanco as well as coarse of levofloxacin; 3)thrombocytopenia with
PLT as low as 20 and then stabalized in the 60-90s thought [**2-5**]
splenic sequestration and marrow suppression from acute
infection; 4)epidural abscess at L5-S1 and progressive
osteomyelitis/lumbar discitis of L4-S1 with recurrent fevers
despite 2 weeks of therapeutic antibiotics; 4)[**Last Name (un) **] thought [**2-5**]
ATN with Cr peaking at 2.8 and trending down to 1.5, renal US
unremarkable; 5)oral herpes outbreak treated with acyclovir.
While at OSH, pt had persistent low back pain, T=103 daily, WBC
10 with 10% bands, dohle bodies on smear. He had TEE and TTE
showing no valve vegetations and EF 55%.
Abd U/S performed: cirhosis. MRI lumbar spine showed interval
developmenet of enhancement of L4 and L5 vertebral bodies, mild
enhancement of L5-S1 disc and enhancement of epidural space from
L3-S1, suggestive of epidural abscess and L4-L5 osteomyelitis.
ID, Neurosurgery, IR were all consulted at OSH and reccomended
abscess drainage and transfered him to [**Hospital1 18**] for this procedure.
OSH relevant labs: Cr 2.82, BUN 39, HCT 32, PLT 21, WBC 10, CPK
4,000, ALP 197.
Hep A neg, IgM neg, hepatitis C RNA neg, hep B DNA neg, RPR neg,
syphillis IgG equivical. HIV neg. Cryoglobulin neg. CRP 65, ESr
140.
Upon transfer to the floor,pt states that he has bilateral
buttocks/low back pain. Non radiating. Also reports weakness of
bilateral lower extremities, making it difficult for him to
walk. No numbness, no urinary or bowel incontinence. Pt states
his last drink was 2 months ago. No IV drugs, no injuries while
at work recently. Says he used to be a big drinker. Neg HIV.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
ALL WERE DIAGNOSED AT OSH on recent admission, prior to [**2-/2172**]
pt had no known medical issues:
MSSA bacteremia- [**3-/2172**]
ETOH abuse
Aspiration pna-multifocal pna when over-sedated with benzos for
ETOh withdrawel
Cirhosis
HTN
HLD
Vertebral osteomyelitis and epidural abscess- [**3-/2172**], per OSh
records
Social History:
Capenter. From the [**Country **] republic. Lives with wife. 4
children from prior partner. Non [**Name2 (NI) 1818**]. Big drinker "in the
past" per pt
Family History:
father- MI at age 78
Physical Exam:
Admission Exam:
VS - Temp 98.7 F, 117/70 BP , 85 HR , 18 R , O2-sat 96% RA
GENERAL - NAD, comfortable, appropriate, long eye lashes
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, 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 - systolic murmur at left sternal border, non radiating
ABDOMEN - non tender, non distended, pos bs, no obvious ascites,
neg fluid wave
EXTREMITIES - no pedal edema, palp bilateral pulses
SKIN - no rashes or lesions. Has [**Doctor First Name **] nails.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, [**4-7**] stregnth if
bilateral iliopsoas muscles, toe extensors [**4-7**] on right and
3.5/5 on left. Diminished quadruceps reflexes bilaterally. Has
sensation to touch bilaterally. Decreased sensatin to vibration
at bilateral toes and ankles. normal finger to nose. EOM in
tact. Remainder strength is [**5-7**] and sensation throughout. Pain
to palpation in bilateral buttocks regions, around the area of
the sacrum.
DISCHARGE PHYSICAL EXAM:
VS: Tm 100.3, Tc 99.6 140/96 (140-166/82-96), HR 100 (92-102),
24 (20-24), 99%RA (99-100%RA)
GEN: awake, sitting up in bed, appears comfortoable, AAOx3, NAD
HEENT: sclera non-icteric, dry MM, JVP flat
CV: nl S1, S2, no RRR, 2/6 systolic murmur at LUSB, no r/g
PULM: no use of accessory muscles, CTAB without wheezes or
crackles
ABD: +BS, soft, NT, ND
EXT: trace peripheral edema on LE's bilateral to ankles.
NEURO: AAOx3, CN II-XII grossly intact, moving all extremities,
no gross deficits
Pertinent Results:
ADMISSION LABS [**2172-3-25**]:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.2 2.41* 8.3* 24.5* 102* 34.5* 34.0 18.2* 62
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
77* 0 13* 7 1 0 0 2* 0
PT PTT Plt Ct INR(PT)
17.4* 35.3* 62* 1.6*
ESR CRP
143 19.6
Glucose UreaN Creat Na K Cl HCO3 AnGap
105*1 26* 1.5* 136 4.1 102 29 9
ALT AST AlkPhos TotBili Lipase
48* 66* 192* 1.7* 432*
Albumin Calcium Phos Mg Iron Ferritin
2.0* 8.0* 4.4 1.8 83 701
DISCHARGE LABS [**2172-4-6**]:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.9 2.37* 8.0* 23.8* 101* 33.6* 33.4 19.6* 65*
Neuts Lymphs Monos Eos Baso
61.8 28.9 7.4 1.5 0.4
Glucose UreaN Creat Na K Cl HCO3 AnGap
112*1 18 1.0 137 3.6 105 27 9
IMAGING:
MRI [**2172-3-25**]:
IMPRESSION: 1. The apparently known L4 through S1 vertebral
osteomyelitis with intervening discitis is confirmed. There is
an extensive associated
multilocular abscess in the ventral epidural space, which
occupies a large amount of the canal cross-sectional area, with
marked mass effect upon and effacement of the thecal sac and
compression of the cauda equina nerve root
within. 2. Prominent enhancing tissue dorsal to the more
cephalad portion of the L4 and the L3 vertebrae. Given the
overall appearance, this more likely represents epidural venous
engorgement in response to the inflammatory process, above,
superimposed on relatively severe spinal canal stenosis at the
L3-L4 level, on a degenerative basis. 3. No definite other focus
of infection is identified, elsewhere in the imaged lumbar
spine. 4. Marked deep paraspinal muscle edema and enhancement,
without evidence of liquefactive necrosis; while this may simply
be reactive in nature, contiguous involvement and pyogenic
myositis is not completely excluded. 5. Unremarkable appearance
to the largely included SI joints, without evidence of septic
arthritis.
CXR [**2172-3-25**]:
No previous images. Low lung volumes may account for some of the
prominence of the transverse diameter of the heart. No evidence
of acute
focal pneumonia, vascular congestion, or pleural effusion on a
somewhat
limited study.
CT ABDOMEN/PELVIS [**2172-3-25**]:
CT abd and pelvis with contrast: 1. No evidence of
intra-abdominal or intrapelvic abscess, as questioned. 2.
Redemonstration of known discitis of the L4-S1 vertebral body
levels. The known epidural component is not well evaluated on
this study. 3. Edema within the left gluteus musculature. 4.
Esophageal and gastric varices, findings compatible with the
provided history of cirrhosis.
ECHOCARDIOGRAM (TTE) [**2172-3-26**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No masses or vegetations are seen on the aortic valve.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Normal
left ventricular cavity size and wall thickness with preserved
global and regional biventricular systolic and diastolic
function. No echocardiographic evidence of endocarditis. No
clinically significant valvular disease. Normal pulmonary artery
systolic pressure.
ABDOMINAL U/S [**2172-3-29**]:
IMPRESSION: 1. Cirrhotic liver with patent liver vessels. No
intra- or extra-hepatic biliary duct dilatation. 2. Small right
pleural effusion and atelectasis. 3. Splenomegaly. 4. No
hydronephrosis. 5. No fluid collection in the subcutaneous
tissue at the area of redness in the left flank.
ECHOCARDIOGRAM (TTE) [**2172-3-30**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2172-8-26**], no change.
RIGHT KNEE, ANKLE PLAIN FILMS [**2172-3-30**]:
IMPRESSION: 1. Equivocal right knee joint effusion. Probable
soft tissue swelling. 2. Minimal degenerative changes in the
right knee and ankle. 3. Right knee x-ray examination otherwise
within normal limits. 4. Right Ankle -- no definite lytic or
sclerotic lesion
CXR [**2172-3-31**]: FINDINGS: In comparison with the study of [**3-29**],
there is increased opacification at the right base, concerning
for pneumonia. Prominence of pulmonary vessels suggests a
possible overhydration.
CXR [**2172-4-2**]: IMPRESSION: Persistent opacity at the right lung
base may represent atelectasis and a small right pleural
effusion; however, pneumonia cannot be excluded.
MICROBIOLOGY:
[**2172-4-3**] JOINT FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL INPATIENT
[**2172-4-2**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2172-4-1**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2172-3-31**] BLOOD CULTURE: NEGATIVE
[**2172-3-31**] BLOOD CULTURE: NEGATIVE
[**2172-3-30**] JOINT FLUID: NEGATIVE
[**2172-3-30**] BLOOD CULTURE: NEGATIVE
[**2172-3-28**] BLOOD CULTURE: NEGATIVE
[**2172-3-28**] URINE URINE CULTURE: NEGATIVE
[**2172-3-28**] BLOOD CULTURE: NEGATIVE
[**2172-3-28**] URINE URINE CULTURE: NEGATIVE
[**2172-3-27**] BLOOD CULTURE: NEGATIVE
[**2172-3-27**] MRSA SCREEN MRSA SCREEN: NEGATIVE
[**2172-3-27**] TISSUE GRAM STAIN from epidural abscess:
NEGATIVE
[**2172-3-27**] BLOOD CULTURE: NEGATIVE
[**2172-3-26**] BLOOD CULTURE: NEGATIVE
[**2172-3-25**] BLOOD CULTURE: NEGATIVE
[**2172-3-25**] BLOOD CULTURE: NEGATIVE
[**2172-3-25**] URINE URINE CULTURE: NEGATIVE
[**2172-3-25**] BLOOD CULTURE: NEGATIVE
[**2172-3-25**] BLOOD CULTURE: NEGATIVE
[**2172-4-2**] (of note, this was gotten from the OSH from the
original positive BCx and just run in our lab on [**4-2**]):
Time Taken Not Noted Log-In Date/Time: [**2172-4-2**] 2:07 pm
BLOOD CULTURE
ISOLATE FROM [**Hospital6 **] FOR SENSITIVITIES
INCLUDING
DAPTOMYCIN AND LINEZOLID.
**FINAL REPORT [**2172-4-6**]**
ISOLATE FOR MIC (Final [**2172-4-4**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = SENSITIVE ( 0.5 MCG/ML ).
TETRACYCLINE REQUESTED BY DR [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
LINEZOLID------------- 2 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
52 M with history of ETOH abuse transfered from OSH for concern
of epidural abscess and osteomyelitis in L4-S1 region. OSH
hospital coarse complicated by: new dx of ETOH cirhosis, [**Last Name (un) **]
with Cr peaking at 2.8 thought to be ATN, persistent fevers
despite adequate antibiotic coverage.
ACTIVE ISSUES:
Epidural abscess/osteomyelitis: MRI performed here revealed
L4-S1 osteomyleitis and L5-S1 epidural abscess. Pt denied being
IV drug user and no recent injuries at work. He does have new dx
of ETOH cirhosis from OSH, likely putting him at risk for
infections. At OSH, 2 blood cx grew MSSA and he was continued on
nafcillin. Pt continued to spike daily fevers up to 102.3 and
had persistent LE weakness 4/5 of bilateral iliopsoas. He had
preserved rectal tone. Neurosurgery evaluated pt and took him to
the OR for lumbar laminectomy L4 and L5 with decompression,
removal of soft tissue on [**2172-3-27**]; overall impression
intraoperatively was of no significant collection. ID team was
consulted and recommended changing nafcillin to daptomycin in
the setting of worsening renal function and concern for AIN.
Antibiotics were subsequently broadened as below given
persistent high fever despite negative culture data. However, ID
decided to switch back to nafcillin when sensitivities of
oringinal BCx returned from OSH. Patient will need to be on an
8 week course of antibiotics with start date per ID considered
[**3-27**] and stop date therefore [**5-22**]. He is going to rehab to
finish this ABx course. He has ID f/u appt already, and will
have weekly labs drawn and faxed to the [**Hospital 4898**] clinic.
Fevers: Pt had daily fevers with Tmax > 102-104 until hospital
day #7, when he defervesced. Suspected primary source remained
osteomyelitis of vertebral bodies and epidural abscess, though
there was also suspected contribution from gout (see below). Pt
had 2/6 systolic murmur at left sternal border, however, TEE at
OSH unremarkable for endocarditis. Pt had TTE here [**2172-3-26**] which
showed no vegetations of valve; this was repeated on [**2172-3-30**]
given persistent high fevers and remained negative for
vegetation. CT Abd/pelvis did not reveals any other abscess or
abdominal sources of infection. Pt was noted to be delirious
with high fever and was uncomfortable from rigoring; he
therefore received several doses of demerol PRN and was also
placed on standing acetaminophen at 500 mg PO/PR Q6H (limited to
2 g per day given liver function). On [**2172-3-31**] antibiotics were
broadened from daptomycin alone to include vanco/cefepime/cipro,
colchicine was started for treatment of gout, and NSAIDs were
started in addition to acetaminophen in the setting of improved
creatinine. He was noted to defervesce that day in the setting
of these changes with improvement in his mental status. His
Tmax since starting ibuprofen in addition to tylenol has been
100.3, and much of his fevers have been attributed to his gout
flare.
Gout: Pt was noted to have right knee pain with small effusion
on [**2172-3-29**] which expanded overnight; additional right ankle
swelling was noted. Orthopedic consult was called and joint
fluid was drained from the right knee (results significant for
WBC 29,500 and + monosodium urate crystals). Rheumatology
consult was called for assistance with management and patient
was started on colchicine for gout. Joint fluid cultures were
negative for infection. Pt was given a steroid injection to R
knee on [**2172-4-3**] with good effect. He has a rheum f/u appt and
will go to rehab on 0.6mg cochicine.
Cirhosis: pt with significant ETOH history and has new dx of
ETOH cirhosis from OSH (2/[**2172**]). Albumin 2.0, INR 1.6, [**Female First Name (un) **]
1.7, AST 66 ALT 48. CT abd here reveals some esophageal and
gastric varices, liver cirhosis, no ascites. Pt with [**Doctor First Name **] nails
on exam. Pts underlying liver disease likely predisposing him to
epidural abscess/osteo. He was started on lactulose given his
altered mental status, though no significant improvement was
noted until his fever was controlled. Abdominal ultrasound
showed normal portal flow.
s/p Aspiration Pneumonia: pt had aspiration event at OSH in
setting of oversedation from ETOH withdrawel medications. He was
intubated. CXR at that time revealed multifocal pna and he was
given gram neg and pos coverage. Patient was periodically noted
to desaturate and was at times on 2-3L of O2 by NC. He was also
noted to be intermittently wheezy on exam, for which he received
albuterol (by neb when able to tolerate mask, also ordered for
MDI). This improved throughout his course.
Acute Kidney Insuficiency: Patient was initially noted to have
creatinine of 2.8 at OSH which trended down to 1.5. Per OSH, pt
had ATN of unknown etiology. Creatinine was 1.5 on arrival here
and improved to 1.3; then began rising to maximum of 2.9.
Nafcillin was stopped in the setting of concern for possible
AIN. Over the subsequent 2-3 days, the patient was noted to
undergo autodiuresis with improvement in his renal function to
creatinine of 1.2. Abdominal ultrasound showed no
hydronephrosis. His Cr at dispo was 1.0.
Anemia: Patient's hematocrit was noted to trend down to a nadir
of 21.7 on [**2172-4-1**]. He was noted at this time to have
guaiac-positive stool. He was also known to have lost
significant blood to repeated phlebotomy including repeated
blood cultures, and without any further intervention this
improved to 23.8.
Pending Labs:
BCX [**4-1**]
BCx [**4-2**]
Transitional Issues:
-Full Code
-ETOH abuse
Medications on Admission:
Motrin PRN
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
8. Maalox Total Relief (bismuth) 525 mg/15 mL Suspension Sig:
One (1) ML PO QID (4 times a day) as needed for mouth pain.
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
12. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing if unable to tolerate neb.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain, fever.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for n/v.
18. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): 8 week course with start date
[**3-27**] and end date [**5-22**].
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Hospital1 **]
Discharge Diagnosis:
Epidural Abscess
Osteomyelitis of L4-S1
Bacteremia
ALcoholic Cirhosis
Thrombocytopenia
Hypoalbuminemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for an abscess and infection
of your spinal cord. You were given antibiotics through your
veins. You also had a procedure where they cleaned out the
infection.
You were also found to have liver problems, likely from your
drinking alcohol. This is very serious and it is very important
to stop drinking to protect your liver from continued damage.
Medication Changes:
As you were only taking PRN Motrin prior to this
hospitalization, we made many changes to your medications list.
The final medications list you will go home on will be
determined by your course at rehab. For further information see
medication list attached to this discharge paperwork as they are
all new medications for you.
It was a pleasure providing care for you during your
hospitalization.
Followup Instructions:
You will be going to a rehabilitation facility. We recommend
that you acquire a PCP in this country if you plan to stay, or
see your PCP at home when you return. You should see your PCP
(either yor new one if you choose to get one, or your old one)
in [**2-6**] weeks after you leave rehab. If you want a PCP at [**Hospital1 18**],
you can call [**Telephone/Fax (1) 250**] to arrange this.
Department: RHEUMATOLOGY
When: THURSDAY [**2172-4-30**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2172-5-15**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 2761, 2724, 2749, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4427
} | Medical Text: Admission Date: [**2167-8-19**] Discharge Date: [**2167-8-25**]
Date of Birth: [**2095-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Elective CABG
Major Surgical or Invasive Procedure:
[**2167-8-19**] CABGx3(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **])
History of Present Illness:
This is a 72 year old male with prior history of coronary
disease. He suffered an MI in [**2155**] followed by PTCA of LAD and
LCX at that time. In [**2167-1-20**], stress testing was positive for
ischemia with imaging showing an ejection fraction of 54%.
Subsequent echocardiogram in [**2167-3-22**] was notable for an LVEF of
45% with mild AI and mild MR. [**First Name (Titles) **] [**Last Name (Titles) 29817**] in [**Month (only) 216**]
[**2166**] revealed severe three vessel coronary disease with mildly
depressed LV function. Angiography showed a totally occluded
obtuse marginal and right coronary artery while the LAD had an
70% lesion. There was no mitral regurgitation and the LVEF was
estimated at 40%. Based on the above results, he was referred
for cardiac surgical intervention.
Past Medical History:
CAD - as above, Hypertension, Hypercholesterolemia, Prostate
Cancer - s/p XRT, Colon polyps, s/p Gingival surgery
Social History:
Quit tobacco [**2141**], 25 pack year history. He denies ETOH. He
lives with his nephews in [**Location (un) 1514**], MA. He is retired.
Family History:
No premature coronary disease.
Physical Exam:
Vitals: BP 146/60, HR 62, SAT 98% RA
GEneral: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Heart: regular rate, no murmur, normal s1s2
Lungs: clear bilaterally
Abdomen: soft, nontender
Ext: warm, no edema
Pulses: 2+ distally, no carotid bruits
Neuro: nonfocal
Pertinent Results:
[**2167-8-25**] 06:25AM BLOOD WBC-6.3 RBC-3.65* Hgb-10.9* Hct-32.1*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.1 Plt Ct-218
[**2167-8-25**] 06:25AM BLOOD Glucose-113* UreaN-24* Creat-0.8 Na-135
K-4.1 Cl-98 HCO3-29 AnGap-12
[**2167-8-25**] 06:25AM BLOOD Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent three vessel coronary
artery bypass grafting by Dr. [**Last Name (STitle) **]. The operation was
uneventful and he transferred to the CSRU for invasive
monitoring. He initially required multiple blood products for a
coagulopathy. Over the next 24 hours, his bleeding improved. By
postoperative day one, he awoke neurologically intact and was
extubated without incident. Amiodarone therapy was initiated for
episodes of atrial fibrillation. Beta blockade was also resumed
and advanced for rate control and hypertension. Chest tubes and
pacing wires were removed without complication. He experienced
some confusion which temporarily required close observation. He
otherwise maintained stable hemodynamics and transferred to the
SDU on postoperative day four. He eventually converted back to a
normal sinus rhythm and no further atrial arrhythmias were
noted. Over several days, his mental status improved. Medical
therapy was optimized and he continued to make clinical
improvements. He was eventually cleared for discharge to home on
[**2167-8-25**]. At discharge, he was near his preoperative weight with
room air saturations of 94%.
Medications on Admission:
Lopressor 100 [**Hospital1 **], hCTZ 25 qd, Cozaar 100 qd, Felodipine 5 qd,
Zocor 40 qd, Aspirin 325 qd, Centrum, Vit C, Vit E, Citracel
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Losartan 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
11. Coumadin 5mg PO QD
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
HTN
^chol.
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.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Call our office for sternal drainage, temp. > 101.5.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 2739**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Make an appointement with Dr. [**First Name (STitle) **] for 2 weeks.
Completed by:[**2167-9-9**]
ICD9 Codes: 2720, 4019, 2930, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4428
} | Medical Text: Admission Date: [**2197-10-16**] Discharge Date: [**2197-10-19**]
Date of Birth: [**2128-8-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2197-10-18**]
Laparoscopic cholecystectomy
History of Present Illness:
69M with history of gastric bypass presents with 3 days of
RUQ abdominal pain and jaundice. Patient had sudden onset of RUQ
pain 3 days ago after a large dinner. His pain has decreased
slightly since then, but has not completely resolved. He denies
nausea and vomiting but had one episode of diarrhea when his
pain
started. He has been feeling weak, ill, and had a fever to 101
today. He reports episodes of abdominal pain after meals in the
past, but has never been told that he has gallstones.
Patient was initially seen at [**Hospital1 18**] [**Location (un) 620**] where he was in new
afib with RVR to 120s. He was afebrile at the time, but appeared
jaundiced. He was fluid resuscitated and transferred to [**Hospital1 18**]
[**Location (un) 86**] for management of possible cholangitis. On arrival to ED,
patient was still in afib but down to 100s. He reported
persistent RUQ pain but denied nausea, chills, and vomiting.
Past Medical History:
1. Morbid obesity - pt has lost 145 lbs
2. hypertension - now improved
3. hyperlipidemia - now improved
4. Obstructive sleep apnea - now improved
PSH:
1. Mini-gastric bypass surgery ~10 months ago
2. left thigh tumor excision
3. right inguinal hernia repair
Social History:
Pt denies tobacco or alcohol use. He has 2 kids and works in
sales.
Family History:
Father had MI.
Physical Exam:
Temp 100.1 HR 100 BP 144/83 RR 16 O2 sat 94% RA
Gen: Appears jaundiced and dehydrated, NAD
CV: Irregular
Resp: CTAB, no distress
Abd: Soft, midly distended, tender in RUQ and mildly tender in
epigastrium, midline scar noted with laparoscopic scars as well,
no rebound or guarding
Ext: Warm, well perfused
Pertinent Results:
[**2197-10-16**] 11:20PM WBC-12.2*# RBC-4.55* HGB-13.6* HCT-39.1*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.2
[**2197-10-16**] 11:20PM NEUTS-94.7* LYMPHS-3.9* MONOS-1.2* EOS-0.1
BASOS-0.1
[**2197-10-16**] 11:20PM PLT COUNT-133*
[**2197-10-16**] 11:20PM PT-16.6* PTT-31.6 INR(PT)-1.5*
[**2197-10-16**] 11:20PM ALT(SGPT)-232* AST(SGOT)-97* ALK PHOS-204*
TOT BILI-3.8*
[**2197-10-16**] 11:20PM GLUCOSE-124* UREA N-27* CREAT-1.2 SODIUM-138
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2197-10-17**] MRCP :
1. Cholelithiasis with a small amount of pericholecystic fluid.
No biliary
duct dilatation.
2. Multiple renal cysts with a single hemorrhagic cyst in the
upper pole of the left kidney.
3. Stable left adrenal adenoma.
4. Multiple small pancreatic cysts, the largest is an 8-mm cyst
in the
pancreatic head, given the patient's age, recommend followup
with repeat MRCP in one year.
Brief Hospital Course:
Mr. [**Known lastname 2405**] was evaluated by the Acute Care team in the
Emergency Room and based on his symptom, leukocytosis and
physical exam he was admitted to the hospital with cholangitis
and atrial fibrillation. For that reason he was monitored in
the ICU where he was made NPO, hydrated with IV fluids and given
broad spectrum antibiotics. He received one dose of lopressor
for rate control of his afib and responded well. His initial T
Bili was 6 and ERCP was recommended but due to his prior gastric
bypass surgery it would be too difficult therefore MRCP was
performed that showed cholelithiasis with pericholecystic fluid.
All of his LFTs were trending down after 24 hours suggesting
that a stone may have passed. His creatinine was 1.5 at the
outside hospital but quickly declined with adequate fluid
hydration. He was transferred to the floor on [**2197-10-17**] in good
condition.
Following transfer his LFT's were monitored and his T Bili
decreased to 1.5 therefore plans were made for a laparoscopic
cholecystectomy . He was taken to the Operating Room on
[**2197-10-18**] and underwent a laparoscopic cholecystectomy. He
tolerated the procedure well and returned to the PACU in stable
condition. He maintained stable hemodynamics and his pain was
well controlled. He was transferred back to the Surgical floor
and continued to make good progress. His diet was gradually
advanced and was tolerated well. He was up and walking without
difficulty and his pain was well controlled. His port sites
were dry.
He remained in rate controlled atrial fibrillation since his
admission in the 70-80 range with a blood pressure of 120/80.
He has no associated symptoms and preferred to follow up with
his Cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) **]. After discussing the
situation with Dr. [**Last Name (STitle) **] he recommended starting an aspirin a
day and he will see him in his office next week for further work
up.
He was discharged to home on [**2197-10-19**] with a total bili of 1.1
and a creatinine of 1.2.
Medications on Admission:
Benicar 40', omeprazole 20'
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute cholecystitis
2. Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
You also have an irregular heart beat which will need to be
followed. You have a visit with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**].
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-7**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Name (STitle) 766**], [**2197-10-23**] at 1:50PM at [**State 71623**]. [**Location (un) 3678**], MA. ( [**Telephone/Fax (1) 18278**].
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-26**] weeks.
Call Dr. [**Last Name (STitle) **] for a follow up appointment in [**12-25**] weeks.
Completed by:[**2197-10-19**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4429
} | Medical Text: Admission Date: [**2147-8-25**] Discharge Date: [**2147-8-30**]
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Fall, with a left facial droop, neglect the left hemispace, and
right gaze deviation
Major Surgical or Invasive Procedure:
Intubation and extubation
Angiography - with an unsuccessful attempt to use the penumbra
clot retrieval device and ultimate treatment with local IA t-PA
History of Present Illness:
Mrs [**Known lastname **] is an 89 RHF with complex PMH including PVD, CAD,
HTN, DMII, hypercholesterolemia, and afib on coumadin who fell
at home at 2:45. She was feeling well and was on the telephone
prior to the fall. She bent down to write something that was
being told to her on the phone. She fell out of her chair and
found herself unable to get up. She was able to call for help
from the front desk at her [**Hospital3 **] facility. She was
brought in by EMS. Initial finger stick was 123. On arrival
here the patient was noted to have a left facial droop, neglect
the left hemispace, and have right gaze deviation.
Code stroke called at 3:26. Her initial NIHSS was deferred for
head imaging given the patient's anticoagulation and suspected
hemorrhage. NIHSS:Total score 10.
Past Medical History:
CHF
Hypothyroid
Afib on coumadin s/p ablation.
HTN
DMII
Hyperlipidemia
CAD
Spinal stenosis
Uterine CA
PNA
PVD
GERD
Social History:
Widowed, recently moved to an [**Hospital3 **] facility.
Non-smoker.
Family History:
Non-contributory.
Physical Exam:
BP: 152/78; HR: 64 (sinus on tele); RR: 12; SaO2: 98%RA
Gen: Alert, oriented. Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Initial Neurological Examination:
>>MS??????Alert. Oriented to self, location, date. Apt historian
(watched vice presidential debate last night; worried about
economy and aware of impending legislation in Congress). Speech
fluent, but labially dysarthric. No paraphasic errors.
Registration, repetition, recall intact.
>>CN??????Fundi w/ sharp discs. PERRL. Does not blink to threat on
LEFT. No ptosis. Forced right gaze deviation but w/ coaching is
able to briefly cross left of midline voluntarily. Facial
sensation and pterygoid strength intact. Moderate central LEFT
facial weakness. Hearing intact to finger rub. Palate elevates
midline. SCMs intact. Tongue protrudes midline.
>>Motor??????R UE [**3-27**] prox and distally. R LE [**3-27**] prox and distally.
L UE [**3-27**] prox and distally. L LE 5-/5 proximally but [**3-27**]
distally. L leg drift.
>>Sensory??????Decreased sensation to touch/nox on left side. Visual
and tactile extinction.
>>DTRs??????L/R: bic [**11-22**], br tr/tr, tri 0/0; pat 0/0; Ach 0/0. LEFT
plantars extensor.
>>Coord/Gait??????No dysmetria by FTN and HTS. Did not ambulate.
1a LOC =0
1b Orientation =0
1c Commands =0
2 Gaze =2
3 Visual Fields =2
4 Facial Paresis =2
5a Motor Function R UE =0
5b Motor Function L UE=0
6a Motor Function R LE=0
6b Motor Function L LE=0
7 Limb Ataxia =0
8 Sensory perception =1
9 Language =0
10 Dysarthria = 1
11 Extinction/Inattention =2
TOTAL = 10
Pertinent Results:
Cardiology Report ECG Study Date of [**2147-8-25**] 3:20:54 PM
Sinus rhythm. First degree A-V block. Borderline left axis
deviation with
probable left anterior fascicular block. Lateral ST-T wave
changes. Cannot
rule out myocardial ischemia.
CXR [**2147-8-26**]
Ill-defined opacities worse in the bases and more so in the left
side are worrisome for aspiration given the provided clinical
history,
although there are no prior studies available for comparison to
assess its
chronicity. There is no pneumothorax or large pleural effusions.
There is
mild cardiomegaly.
Pelvis AP X-Ray [**2147-8-26**]
There are no fractures. Mild degenerative changes are in the
right hip joint. Moderate degenerative changes are in the lower
lumbar spine. Right femoral catheter is in place. Surgical clips
are in the left pelvis. Contrast material is in the bladder and
partially obscures the sacrum.
Left Wrist X-ray [**2147-8-28**]
Three radiographs of the left wrist demonstrate diffuse
demineralization.
There is moderate-to-severe subchondral sclerosis, joint space
narrowing, and marginal osteophyte formation about the first CMC
joint. Chondrocalcinosis about the radiocarpal and intercarpal
joint spaces is present. No discrete fracture is identified. The
regional soft tissues are unremarkable.
CThead/CTA/CT perfusion [**2147-8-25**]
1. Acute distal M1 occlusion of the right middle cerebral artery
with large at risk region of ischemic penumbra.
2. Calcified atherosclerotic plaque involving the carotid
arteries
bilaterally with 50% stenosis at the origin of the left internal
carotid
artery and 20% at the right. Heavy calcified atherosclerotic
plaques are
present within bilateral carotid siphons.
3. Atheromatous ulcerations within the aortic arch only
partially evaluated on this study.
4. Diffuse interstitial abnormality within the lung apices .
Dedicated CT of the chest may be warranted as clinically
indicated.
MRI of the head [**2147-8-26**]
Areas of small infarcts in the distribution of right middle
cerebral artery without evidence of mass effect, midline shift,
hydrocephalus
or signs of hemorrhage.
MRA of the head [**2147-8-26**]
Motion limited study demonstrating flow signal in both middle
cerebral arteries without evidence of occlusion.
ECHO (TTE) [**2147-8-29**]
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets (3) are moderately thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional systolic
function. Mild right ventricular dilation with preserved
systolic function. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
[**2147-8-28**] VIDEO OROPHARYNGEAL SWALLOW
The study was performed in collaboration with the speech and
swallow service. In brief, the oral phase was unremarkable with
the exception of mild pre-spillage of thin liquids. Pharyngeal
phase was notable for episodes of flash penetration with sips of
thin liquid that
cleared with swallowing. No episodes of aspiration were seen.
IMPRESSION: Pre-spillage and flash penetration with thin
liquids. No episodes of aspiration.
Lab results
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2147-8-30**] 06:20AM 9.6 4.43 13.1 38.8 88 29.5 33.7 16.2*
341
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2147-8-30**] 06:20AM 341
[**2147-8-30**] 06:20AM 40.0* 40.7* 4.3*
MISCELLANEOUS HEMATOLOGY ESR
[**2147-8-28**] 12:55PM 95*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2147-8-30**] 06:20AM 138* 24* 1.1 136 4.4 104 24 12
[**2143-8-26**] 8.2%
Brief Hospital Course:
Mrs [**Known lastname **] was admitted on the [**8-25**], she had a right
MCA syndrome that was confirmed by a CT brain perfusion study.
Her initial NIHSS was 10. Her INR precluded IV TPA. She
therefore received intra-arterial 5 mg TPA. She was intubated
for the procedure and successfully extubated. Her neurological
examination significantly improved prior to discharge: language
was normal, and she had a very mild right sided hemiparesis, and
was able to walk with a walker.
Hospital course is reviewed by the following problem list:
Neurology
Her Coumadin dose on [**8-30**] was held due to the INR (4.3), her
level needs checking, and she should be restarted on an
appropriate dose.
Cardiology
Her Imdur 30 mg was kept on hold after the stroke. Digoxin was
stopped due to symptomatic pauses>3s and bradycardias of 30-40s.
Her cardiologist from [**Hospital1 **] - Dr [**Last Name (STitle) **] [**Name (STitle) 2257**] 1 [**Telephone/Fax (1) 92828**]/1 [**Telephone/Fax (1) 92829**] was updated about the hospital course. Her
PCP from [**Hospital1 92830**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 1 [**Telephone/Fax (1) 92831**], was
[**Name (NI) 653**], and messages were left for her to get in touch with
the stroke Neurology service at [**Hospital1 18**].
Musculoskeletal
Due to her diffuse muscular pains, an ESR was checked which was
elevated. It will need repeating because it may be elevated in
the context of a stroke. She may have polymyalgia rheumatica, if
these muscular pains continue. Incidentally, her CK was not
elevated.
Her X-Rays of the pelvis and hand suggested osteopenia, and she
would benefit from an outpatient DEXA scan and bisphosphonates
if appropriate. The calcium and vitamin D are on hold, as these
interact with thyroxine to reduce the absorption.
Respiratory
She has orthopnea, and she has been restarted on Lasix (half of
her usual dose).
GI/Nutrition
VIDEO OROPHARYNGEAL SWALLOW ([**2147-8-28**]): In brief, the oral phase
was unremarkable with the exception of mild pre-spillage of thin
liquids. Pharyngeal phase was
notable for episodes of flash penetration with sips of thin
liquid that
cleared with swallowing. No episodes of aspiration were seen.
Endocrine
Her TSH was 13, therefore her dose of thyroxine was increased.
She was on an insulin sliding scale in the hospital, and
restarted on Januvia prior to discharge.
Dispo
Niece [**First Name5 (NamePattern1) **] [**Name (NI) 92832**]) contact details 1-[**Telephone/Fax (1) 92833**].
Medications on Admission:
Aspirin 81 daily
Calcium carbonate 1250mg daily
Digoxin 0.125mg daily
Ferrous sulfate 325mg daily
Lasix 40mg daily
Imdur - 30mg daily
Januvia 25mg daily
levothyroxine 50mcg daily
Toprol XL 50mg daily
Omeprazole 20mg [**Hospital1 **]
Simvastatin 80mg daily
Vitamin D 400 units daily
Coumadin variable to goal.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
9. Januvia 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Coumadin Oral
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 533**] Centre for Extended Care
Discharge Diagnosis:
Right middle cerebral artery infarct status post intraarterial
tPA
Atrial fibrillation
Hyperlipidemia
Diabetes mellitus
Hypothyroidism
Mild symmetric left ventricular hypertrophy with preserved
global and regional systolic function.
Mild right ventricular dilation with preserved systolic
function. Mild mitral regurgitation.
Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Discharge Condition:
Improved: Language is fluent with intact naming and repetition
and without dysarthria. She has a mild right UMN hemiparesis.
She is able to ambulate with assistance and a walker.
Discharge Instructions:
You have been admitted to the hospital with a stroke. You
received clot-busting medications and have improved
significantly, but will still need rehabilitation.
Take all medications as prescribed, and follow up with your
doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. You will need to have your coumadin levels
(INR) checked frequently and your dose adjusted as needed. One
dose of Coumadin has been held due to your elevated INR, please
get your INR checked tomorrow. Your INR needs to be between 2.5
to 3.
Seek medical attention for any new weakness, numbness, tingling,
change in responsiveness or thinking, difficulty speaking, gait
abnormalities, bleeding, chest pain, difficulty breathing, any
signs of bleeding or spontaneous bruising, or any other new or
worsened symptoms.
Followup Instructions:
Call your primary care physician (Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]) on discharge
from rehabilitation.
Follow up in neurology clinic with Drs. [**Last Name (STitle) 78537**] and [**Name5 (PTitle) **], on
[**10-4**] at 1:30pm
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2147-8-30**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4430
} | Medical Text: Admission Date: [**2117-5-4**] Discharge Date: [**2117-5-18**]
Date of Birth: [**2074-4-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Confusion, Lethargy
Major Surgical or Invasive Procedure:
[**5-5**] Left Craniotomy for SDH evacuation
[**5-6**]: Left Craniotomy for SDH re-evacuation
History of Present Illness:
Patient is a 43M without traumatic head injury history who
presented to the hospital after being pulled over while driving
for erratic driving behavior. When the police officer approached
the patient's car, he was found to be post-seizure, and
incontinent of urine. He was then taken to the OSH emergency
department where a CT scan was performed that identified sizable
bilateral SDH of unclear etiology.
Past Medical History:
1. DM
2. HTN
3. Dyslipidemia
Social History:
Married, resides at home with wife and child. Presently not
working.
Family History:
Non-contribuitory
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: afebrile BP:123/82 HR:93 RR:14 O2Sats: 95%ra
Gen: WD/WN, comfortable, NAD.
HEENT:normocephalic, atraumatic
Pupils: equal; slightly reactive to light
EOMs; unable to maintain attention to follow directions
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, intermittently following commands,
slightly aphasic, cooperative with exam. Opens eyes to voice.
Orientation: Oriented to person, place, and year only.
Language: Slowed speech with impaired comprehension.
Naming intact. Some difficulty with word finding intermittently.
Cranial Nerves:
I: Not tested
II: Pupils equally round and minimally reactive to light, 3mm
bilaterally.
III, IV, VI: patient unable to follow directions
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: Full strength and sensation throughout with exception of
RUE Triceps which is 4+/5.
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
On Discharge
T98.3 103/73, 92,14, 97%RA
Gen: NAD, comfortable
Wound: CDI
Neuro: AOx3, PERRL 3/2mm bilaterally, EOMI intact. Slight right
prontaor drift, but self corrects. No dysmetria. Eyes opening to
voice. Following commands, full strength and power throughout
upper and lower extremities.
Pertinent Results:
CT Scan [**5-4**]: Large bilateral extra-axial subdural hematomas are
seen. The left- sided subdural measures upwards of 2.4 cm in
greatest width. The right-sided measures upwards of 1.6 cm in
greatest width. The subdural hematomas are of mixed attenuation
suggesting acute-on-chronic hemorrhage. Several more linear
areas of hyperdensity within the subdural collection likely
represent fibrovascular strands. There is rightward shift by
approximately 8-9 mm. There is mass effect seen on the left
lateral ventricle. There is effacement of the suprasellar
cistern, concerning for uncal herniation. Effacement of the
basilar cisterns suggests downward transtentorial herniation.
Tonsillar herniation also present. No definite intraparenchymal
hemorrhage identified. Visualized paranasal sinuses are normally
aerated.
CT SCAN [**5-5**](post-evacuation):
FINDINGS: Since the previous study the left-sided subdural
hematoma has been evacuated. There is air seen within the
subdural space. The overall size of the subdural have decreased.
There is somewhat decreased mass effect seen with decreased
midline shift. Right-sided small subdural with a maximum width
of 15 mm is again noted and has not significantly changed in
size. There is no hydrocephalus.
CT Scan [**5-6**]:
1. Increase in size of left temporal extra-axial collection with
increased mass effect on the temporal lobe and temporal horns,
and with slight increase in uncal herniation. There is slight
increase in layering hyperdense blood within the left
extra-axial collection. While there is increase mass effect upon
the left lateral ventricle, there is no change in rightward
shift of normally midline structures. Increased tonsillar edema
is noted, along with slight increase in tonsillar herniation.
Right mixed-attenuation subdural collection unchanged.
CT Scan [**5-7**](post-re-evac):
IMPRESSION:
1. Left subdural hematoma, decreased in size. Extensive
pneumocephalus secondary to craniotomy.
2. Unchanged appearance of the right subdural hematoma.
3. Persistent shift of normally midline structures by
approximately 6 mm, slightly decreased when compared to most
recent prior.
4. Ethmoid and sphenoid sinus air-fluid levels.
CT Scan [**5-7**]:
1. No significant interval change. Unchanged frontoparietal
subdural hematomas bilaterally with mass effect and shift of
midline to the right as described above. Unchanged uncal and
tonsillar herniation.
CT Scan [**5-17**]: IMPRESSION:
1. Slight decrease in size of bilateral subdural hematomas.
2. Mild right midline shift (5 mm), also minimally improved.
3. No new focus of hemorrhage identified.
MRI C-Spine [**5-14**]:
IMPRESSION:
1. Indented appearance to the dorsal aspect of the spinal cord
is noted posterior to the T3 vertebral body. There is an
expanded appearance to the cord above this level, where there is
also slightly increased STIR signal. There is suggestion of a
collection posterior to the cord that may be causing compression
of the cord and this indented appearance. The collection is
relatively isodense compared to CSF fluid. However, it is
incompletely visualized, particularly on axial imaging, and
imaging through the thoracic spine is recommended for further
evaluation.
MRI T-Spine [**5-16**]:
IMPRESSION:
1. Focal dilation of the subarachnoid space, in the posterior
thecal sac, at the level of T2 and T3, 0.9 x 0.5 x 2.0 cm in the
transverse, AP and CC dimensions, and can represent a cyst like
arachnoid cyst. The exact demarcation between the cyst and the
remainder of the subarachnoid space is not clear on the present
imaging. Moderate spinal canal stenosis, moderate compression on
the cord with anterior displacement of the cord, from the cyst
is noted.
2. Mild expansion of the cord just above the location of the
cyst, with T2 hyperintense foci in the right side of the cord
can represent edema versus myelomalacia; no enhancement. It is
unclear from the present imaging if there is any communication
between the cyst and the T2 hyperintense foci in the cord.
Further evaluation of the cyst, can be performed with CT
myelogram _____ there is more accurately the _____ compartments
involved.
3. Possible spinal cord herniation posteriorly, and given the
slight buckling of the cord appearance, noted on the sagittal T2
sequence.
Labs:
[**2117-5-14**] 06:55AM BLOOD WBC-7.0 RBC-4.14* Hgb-12.3* Hct-36.6*
MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 Plt Ct-433
[**2117-5-4**] 09:30PM BLOOD Neuts-80.8* Lymphs-16.4* Monos-2.1
Eos-0.4 Baso-0.4
[**2117-5-14**] 06:55AM BLOOD Glucose-182* UreaN-11 Creat-0.7 Na-140
K-4.5 Cl-101 HCO3-28 AnGap-16
[**2117-5-14**] 06:55AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.8
[**2117-5-18**] 09:15AM BLOOD Phenyto-18.9
Evoked Potentials Study: performed on [**5-18**]; formal read pending.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] from OSH for definitive
management of large bilateral SDH on [**2117-5-4**]. He was admitted
to the ICU for close monitoring in preparation for urgent
evacuation to be performed on [**5-5**] as first case. Patient
tolerated the procedure well (see separately dictated operative
note for details of the operative procedure).
On [**5-6**] CT scan was repeated for a decreased neurologic
examination, and was found to have reaccumulation of SDH and
increased mass effect and shift. He was taken to the operating
room again for re-evacuation of SDH via left craniotomy.
Procedure was tolerated well, and uneventful.
Post-re-evacuation CT revealed decreased size in SDH, and
decreased shift and mass effect. An additional repeat CT was
performed again on [**5-7**] and found to be stable. He was then
extubated and monitored for an additional day in the ICU.
On [**5-8**], he was transferred to the neurosurgical floor, during
which time he progressed well. On [**5-11**],upon returning to
neurosurgical floor after an MRI, he began to have seizures that
lasted for approximately 1hour intermittently despite multiple
dosing of Ativan IV. He was bolused with 500mg of IV dilantin
to further boost therapeutic level. He was urgently transferred
back to the SICU for closer monitoring given new onset of
seizure activity. CT scan was repeated once he was seizure free
for 1/2h and the SDH was found to be essentially stable.
Epilepsy service was also consulted for the ongoing management
of his seizure activity. He was additionally started on Keppra
for additional control. He has been seizure free for two days
at this point and deemed appropriate for discharge to home with
appropriate follow-up with the respectively involved services.
Medications on Admission:
1. Aspirin
2. Insulin and oral diabetic agents(unknown names)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO DAILY (Daily): please administer at noontime.
Disp:*30 Capsule(s)* Refills:*2*
4. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day): please take at 6am and 10pm.
Disp:*180 Tablet, Chewable(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: One (1) 15 units
Subcutaneous dinnertime.
Disp:*QS 100* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection AC, HS: please take regular insulin as a sliding scale
coverage before meals and at bedtime as dictated on sliding
scale sheet given with d/c instructions. .
Disp:*QS 1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Bilateral SDH
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed two anti-seizure medicines, take them
as prescribed and follow up with laboratory blood drawing as
ordered below.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
--------
You also have an appointment with Drs. [**Name5 (PTitle) **] & [**Doctor Last Name **] on
[**2117-6-23**] at 5:00pm in the [**Hospital Ward Name 23**] bldg on the [**Location (un) **]. Their
phone number is [**Telephone/Fax (1) 44**] if you need to reschedule. You will
also need to have your blood dilantin level checked in two
weeks. Please make sure the results are being forwarded to Drs.
[**Last Name (STitle) 2442**] and [**Name5 (PTitle) 12536**]. Their fax number is [**Telephone/Fax (1) 891**].
-------
You [**Month (only) 116**] call the [**Hospital **] Clinic for ongoing diabetes managment if
you wish. Their phone number is [**Telephone/Fax (1) 2378**]. When calling,
identify yourself as a 'new' patient seen during your hospital
stay and your appointment will be assigned accordingly. You may
corrdinate this appointment in the same time frames as your
alternate appointments to ease you commuting difficulties.
Completed by:[**2117-5-18**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4431
} | Medical Text: Admission Date: [**2139-4-24**] Discharge Date: [**2139-5-3**]
Date of Birth: [**2081-4-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
[**4-28**]: Diagnostic Cerebral Angiogram
[**4-30**]: Cerebral Angiogram with embolization
History of Present Illness:
58 RHM with PMH of HTN was brought by EMS to [**Hospital1 18**] ED. HPI
obtained from the family as he was intubated.
Per family, they noted some odd behaviour since last evening. He
had difficulty in identifying people's names and appeared
"somewhat confused." Last night, apparently he left the water
tap
open in the restroom. After waking up this am, he wasnt speaking
up too much and appeared to be "more goofy." He confused his
daughter's name for his wife's. he wanted to get out of the
house
and appeared to be confused and unable to make it. He couldnt
open the door of his garage and his daughter helped him. He
drove
to work around 920am. His family got concerned and tried to
track
him down. He didnt respond to his cellphone and wasnt in the
office when called. When the wife drove to see where he was, she
found him in MVC. Apparently he had a roll over accident and was
very agitated and combative at the site. 911 was called and he
was intubated at the site for "airway" protection. His BP was
high -200 systolic. He was brought to ED. Next, trauma was
called. He was taken to the CT scan and was found to have left
parietal bleed. As expected, neurosurgery and next, Neurology
was
called.
ROS : couldnt be obtained as he was intubated and unable to
provide more history.
Past Medical History:
HTN
anxiety
GERD
Social History:
Lives with wife and daughter. social alcohol use, smokes [**12-21**] ppd
for over 20 years, no drugs, works as a financial adviser.
Family History:
Lung cancer in father, no h/o brain aneurysms or strokes.
Physical Exam:
Vitals: Afeb, 130-140/80, 100 reg, 18 intubated 99 percent
Gen: Intubated , combative
HEENT: NCAT, MMM,
CV: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abd: soft,nondistended, no organomegaly
Ext: warm and well perfused.
Neurologic examination:
Intubated, combative, moving all limbs violently. Doesnt follow
commands.
Pupils equally round and reactive to light, [**3-21**] bilaterally.
blinks to threat on both sides. Fundi normal. EOM difficult to
comment. Face is symmetric.
Moves all limbs violently and symmetrically.
Sensation: withdraws to pain in all limbs.
Reflexes:
+2 and symmetric throughout.
Toes up bilaterally
Coordination/Gait/Romberg: defd
ON DISCHARGE
awake alert oriented x 3 with slight hesitation to answer.
motor exam is full and non focal. He does have a visual field
deficit to Right eye, right inferior quadrant.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2139-5-3**] 05:35 11.3* 4.59* 10.2* 31.6* 69* 22.3* 32.4 15.2
649*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2139-4-30**] 05:45 59 1 22 10 3 1 3* 0 1*
LAB USE ONLY (HEMATOLOGY) I-HOS
[**2139-4-30**] 05:45 DONE
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Burr Tear Dr [**Last Name (STitle) **]
[**2139-4-30**] 05:45 NORMAL 1+ 1+ NORMAL 1+ NORMAL 1+ 1+ 1+
HEMOGLOBIN ELECTROPHORESIS Hgb A Hgb S Hgb C Hgb A2 Hgb F
[**2139-4-24**] 10:50 96.41 0 0 2.5 0.82
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2139-5-3**] 05:35 649*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2139-4-24**] 10:50 404*
LAB USE ONLY
[**2139-5-3**] 05:35
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2139-5-3**] 05:35 1001 19 1.0 138 4.2 102 27 13
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2139-5-1**] 15:14 Using this1
Source: Line-aline
Using this patient's age, gender, and serum creatinine value of
0.8,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2139-4-30**] 05:45 72* 40 268* 652*1 100 0.4
NEW REFERENCE INTERVAL AS OF [**2137-12-23**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
OTHER ENZYMES & BILIRUBINS Lipase
[**2139-4-28**] 06:05 28
CPK ISOENZYMES cTropnT
[**2139-4-25**] 02:30 0.03*1
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2139-5-3**] 05:35 8.9 4.5 2.1
HEMATOLOGIC calTIBC Ferritn TRF
[**2139-4-30**] 05:45 346 73 266
DIABETES MONITORING %HbA1c eAG
[**2139-4-25**] 02:30 5.91 1232
[**Doctor First Name **] RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS
THERAPEUTIC ACTION
ESTIMATED AVERAGE GLUCOSE, CALCULATED FROM A1C USING ADAG
EQUATION.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2139-4-25**] 02:30 234* 336*1 34 6.9 133*
LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
OTHER CHEMISTRY Osmolal
[**2139-5-1**] 15:14 292
Source: Line-aline
PITUITARY TSH
[**2139-4-30**] 05:45 3.3
LAB USE ONLY LtGrnHD
[**2139-4-24**] 10:50 HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Vent Comment
[**2139-4-30**] 09:11 ART 155* 43 7.42 29 3 INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2139-4-30**] 09:11 104 1.2 138 3.9 103
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2139-4-30**] 09:11 10.8* 32 98
CALCIUM freeCa
[**2139-4-30**] 09:11 1.11*
.
Imaging:
[**2139-4-28**] CTA HEAD W&W/O C & RECON:
1. Stable left parietal hematoma with minimal increase in the
surrounding
edema, but no significant change in associated mass effect.
2. No abnormalities identified on the CT perfusion study.
3. Left occipital AVM, with a feeding artery from the slightly
enlarged left posterior cerebral artery and drainage into the
slightly enlarged vein of [**Male First Name (un) 2096**].
4. Slightly enlarged left middle cerebral artery with a likely
feeding branch to the left parietal hematoma, suggesting another
AVM component. Please correlate with the findings of the
preceding conventional angiogram.
[**2139-4-28**] CT BRAIN PERFUSION:
1. Stable left parietal hematoma with minimal increase in the
surrounding
edema, but no significant change in associated mass effect.
2. No abnormalities identified on the CT perfusion study.
3. Left occipital AVM, with a feeding artery from the slightly
enlarged left posterior cerebral artery and drainage into the
slightly enlarged vein of [**Male First Name (un) 2096**].
4. Slightly enlarged left middle cerebral artery with a likely
feeding branch to the left parietal hematoma, suggesting another
AVM component. Please correlate with the findings of the
preceding conventional angiogram.
[**2139-4-27**] CAROT/CEREB [**Hospital1 **]
[**2139-4-26**] ECG: Sinus rhythm. Normal tracing. Compared to the
previous tracing of [**2139-4-24**] the Q-T interval is shorter.
[**2139-4-24**] MR HEAD W & W/O CONTRAST: Findings indicative of left
occipital lobe arteriovenous malformation.
[**2139-4-24**] MRA BRAIN W/O CONTRAST: Findings indicative of left
occipital lobe arteriovenous malformation.
[**2139-4-24**] TRAUMA #3 (PORT CHEST O: 1. Low lung volumes.
Bibasilar opacities, likely reflective of atelectasis, but
infection or aspiratrion are not excluded.
2. Endotracheal tube and nasogastric tube tips in standard
positions.
[**2139-4-24**] CT CHEST/ABD & PELVIS WITH CON:
1. Posterior opacities in the upper and lower lobes of the lung.
Findings
are likely secondary to atelectasis though infection remains
within the
differential in the appropriate clinical setting.
2. Anterior compression deformity of the T6 vertebral body of
uncertain
chronicity. Normal alignment of the thoracolumbar spine.
3. Air within the left external iliac vein. Correlate clinically
for any
recent instrumentation.
4. Left renal cystic lesion. Recommend dedicated renal
ultrasound for
further characterization.
[**2139-4-24**] CT HEAD W/O CONTRAST: prelim - 2.3 x 3.0 x 3.0 IPH in
the left parieto-occipital lobe with surrounding edema. DDx: HTN
hemorrhage, bleeding mass, vascular malformation.
-No scalp hematoma or acute skull fracture.
[**2139-4-24**] CT C-SPINE W/O CONTRAST: No acute fracture or
malalignment. If there is concern for soft tissue or ligamentous
injury, recommend MRI of the cervical spine for further
evaluation.
[**2139-4-28**] CT Perfusion: IMPRESSION:
1. Stable left parietal hematoma with minimal increase in the
surrounding
edema, but no significant change in associated mass effect.
2. No abnormalities identified on the CT perfusion study.
3. Left occipital AVM, with a feeding artery from the slightly
enlarged left posterior cerebral artery and drainage into the
slightly enlarged vein of [**Male First Name (un) 2096**].
4. Slightly enlarged left middle cerebral artery with a likely
feeding branch to the left parietal hematoma, suggesting another
AVM component. Please correlate with the findings of the
preceding conventional angiogram.
[**2139-5-1**] Head CT:
IMPRESSION:
1. Multiple hypodensities within the left cerebellum and
occipital lobe, new
since [**2139-4-24**], are compatible with interval infarction. An
MRI can be
considered for further evaluation.
2. Unchanged left parieto-occipital intraparenchymal hematoma.
3. Status placement of left occipital Onyx embolization material
for a
previously seen AVM.
[**2139-5-2**] MRI BRAIN - done - final read pending at time of
discharge
Brief Hospital Course:
Mr. [**Known lastname 89117**] is a 62M s/p MVC, likely secondary to ICH, seizure
secondary to AVM.
Neurologic: [**4-24**] Head CT revealed 2.3 x 3.0 x 3.0 IPH in the
left parieto-occipital lobe with surrounding edema. [**4-24**] CT spine
with T1 wedge deformity. [**4-24**] MRI brain with Left parietal
intracerebral hematoma with underlying arteriovenous
malformation seen on both MRI and MRA. Pt was evaluated by
neurosurgery and cerebral angio on [**4-28**] revealed an AVM. Keppra
was started for seizure prophylaxis. EEG revealed: no
epileptiform features at this time. On [**4-30**] he returned to the
angio suite and underwent an embolization of the AVM. This was
performed without complication. He was monitored overnight in
the ICU then was cleared for transfer to the SDU on POD#1. Head
CT remained stable.
Cardiovascular: Baseline HTN on home HCTZ and atenolol; PRN
hydralazine and PRN lopressor administered for SBP goal <160
preop. On POD#0 SBP goal was 100-120. This was achieved with IV
Nipride and Nicardipine. On POD#1 SBP was liberalized to <160.
Pulmonary:
- Stable on room air preoperatively but required face tent post
op to keep SPO2>90%.
- Encouraged IS 10 q1hr minimum
- no active issues
Gastrointestinal / Abdomen:
- Bowel regimen
- On home omeprazole
- LFTs mildly elevated but were trending down
Nutrition:
- Regular diet
Renal:
- Voiding
- + UTI / placed on ampicillin x 7 days / enterococcus species
- Replete electrolytes PRN
Hematology:
- SQ heparin started on POD#1
- Hematology/Oncology consulted for abnormal blood smear / large
platelets and increased number of monocytes / no action to be
taken, no asa for now. Pt instructed to follow up with PCP
Endocrine:
- RISS for goal BS < 150
Infectious Disease:
- No active issues
- Blood cultures- NGTD
Medications on Admission:
Atenolol 25
HCTZ 12.5
Prilosec 40
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): you will need to take this for a minimum of 6
months.
Disp:*120 Tablet(s)* Refills:*5*
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*1*
5. olanzapine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): do not take if you are very sleepy .
Disp:*30 Tablet(s)* Refills:*0*
7. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 4 days: you will end this on [**2139-5-8**].
Disp:*32 Capsule(s)* Refills:*0*
8. atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Outpatient Occupational Therapy
cognitive rehab
evaluate and treat
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Arteriovenous Malformation
right hemianopsia
anxiety
thrombocytosis
expressive aphasia
cerebellar infarcts / acute
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
YOU ARE BEING DISCHARGED WITH THE NEED FOR 24 HOUR A DAY
SUPERVISION / YOUR WIFE [**State **] STATES SHE WILL BE ABLE TO
PROVIDE THIS.
Angiogram with Embolization
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? NO DRIVING UNTIL YOU ARE CLEARED TO DO SO BY THE NEUROLOGY
SERVICE
Followup Instructions:
* Please call Dr. [**First Name (STitle) **] / neurosurgery, for a follow up one
month - you will not need imaging at this time. [**Telephone/Fax (1) **]
* The office of Dr. [**Last Name (STitle) 3929**] / Radiation Oncology will be
contacting you for a follow up appointment. You can reach Dr.
[**Last Name (STitle) 3929**] through the brain tumor clinic office phone number at
[**Telephone/Fax (1) **]
* You were seen the the hematology / oncology service because
you had abnormally large platelets and an increased number of
monocytes on a lab test. They are not recommending any action /
medication / or additional testing at this time.
*Please follow up with your primary care physician regarding
your hospital stay and the abnormal blood work
* You will need to follow up with Neurology for your initial
altered
mental status and bleeding in the brain. Please schedule an
appointment to be seen by Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at [**Telephone/Fax (1) **] to
be seen within 2 - 4 weeks
* You will also need to be seen by the Ophthomology department
in [**1-23**] weeks. Please call [**Telephone/Fax (1) **] to schedule an
appointment
* Lastly you will need a DRIVEWISE evaluation before you can
return to driving - their phone number is [**Telephone/Fax (1) **] / a
pamphlet has been provided for you in your discharge paperwork.
Completed by:[**2139-5-3**]
ICD9 Codes: 431, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4432
} | Medical Text: Admission Date: [**2157-8-13**] Discharge Date: [**2157-8-15**]
Date of Birth: [**2080-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever, malaise, jaundice, pancytopenia, lymphadenopathy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
77M with h/o CVA, trigeminal neuralgia, admitted to [**Hospital1 18**] in
[**2157-5-15**] with weight loss and cranial nerve palsies, who
presented to [**Hospital **] Hospital on [**2157-7-30**] with two days of
malaise, fatigue, loss of appetite, gait unsteadiness, LLE rash.
The patient also reported a syncopal episode 2 weeks prior to
admission. He also endorsed one week of night sweats. No HA,
neck stiffness. He was febrile to 101.6 in the ED, WBC 2.2, PLT
140, Na 128, AST 196, ALT 187, AP 379, Tbili 0.8, albumin 2.7,
Cr 0.9. Exam at that time showed him to be fully oriented, with
no focal neuro deficits or jaundice. EKG showed SR without
ischemia, CXR showed hyperinflation, otherwise unremarkable.
Cultures were drawn and he was started on doxycycline for
suspected tick-borne infection (had been recently golfing
outdoors). ID was consulted. Possibilities at that time included
anaplasma, Bartonella, Brucella, CMV, EBV, viral hepatitis.
Bilirubin (mostly direct) began to rise and abdominal ultrasound
and CT were done [**8-2**], showing small ascites and pericholecystic
fluid and no cholecystitis, which was confirmed with negative
HIDA. As part of fever workup, chest CT done which showed
abnormal enlarged R axillary LN with adjacent inflammatory
changes and small b/l pleural effusions. LN biopsy performed
[**8-8**], path pending but per report from pathologist significant
necrosis noted. Given pancytopenia, heme/onc consulted and were
concerned for lymphoma so underwent bone marrow biopsy [**8-11**],
results pending. GI was consulted given rising LFTs and concern
for autoimmune hepatitis and he underwent EGD which showed
[**Doctor Last Name 15532**] dysplasia, esophageal ulcer, hemorrhagic gastritis and
flex sig which was unremarkable. He was started in [**Hospital1 **] PPI.
Tick-borne panel has been negative (lyme, ehrlichia, Babesia),
Monospot negative, Brucella IgG positive, IgM negative, CMV neg,
anaplasma smear negative, [**Doctor First Name **] negative, HIV pending.
Anti-mitochondrial antibiody negative. Hemolytic anemia workup
negative, B12/folate wnl. Flow negative for PNH. ESR 16. CA [**64**]-9
and AFP wnl, ammonia <9. Diagnostic paracentesis also performed
with GS showing rare GPCs in pairs with 169 WBC, 3%PMNs. Cr also
rose to 2.5 from 0.9 at time of discharge, etiology unclear.
On evening prior to transfer, rapid response was called due to
expressive aphasia and RUE weakness. STAT MRI brains howed
acute/subacute infarct in R centrum semiovale area with some
mild atrophy and otherwise unremarkable, which did not fit with
neuro exam at the time. Neurologic deficits (not described)
apparently improved in the time between event and time of
transfer. Warfarin had been held since admission, but INR
therapeutic at the time. Given the complexity of his illness,
the decision was made to transfer him to [**Hospital1 18**] for further care.
VS at transfer: 99.3 119/74 112 20 93%. Upon arrival to [**Hospital1 18**]
floor, he was immediately triggered for AMS and tachycardia to
the 140s and was transferred to the ICU.
Of note, the patient was admitted to [**Hospital1 18**] in [**2157-4-14**] with
cranial nerve palsies, fatigue, and unexplained weight loss. LP
was attempted but unsuccessful. EGD/[**Last Name (un) **] showed rectal ulcers
and Barrett's mucosa. He was also noted to have Hct of 30 during
that admission. CT torso showed no evidence of malignancy at
that time.
On arrival to the MICU, he appears comfortable but is somnolent
but arousable to voice.
Review of systems: Unobtainable. Denies pain.
Past Medical History:
h/o CVA [**2139**] with no residual deficits
trigeminal neuralgia
rectal ulcer
Barrett's esophagus
bilateral cataract surgery [**2152**]
squamous cell skin CA (ear)
BPH- PSA 2.04 in [**2157-1-13**]
hypercholesterolemia
Recent DVT/pulmonary embolism ([**3-27**]), on coumadin
left schwannoma/meningioma
?heterozygous Factor V
Social History:
Lives with his wife in [**Name (NI) 8545**]. Retired truck driver. He
served in the Army in [**Country 2784**] from [**2102**]-[**2104**]. Drinks [**5-19**]
beers/night for years (none x 3 months as of 3/[**2157**]). Smoked
cigars for 30+ years, quit 10 yrs ago. No illicit drugs. 4
children.
Family History:
Sister has [**Last Name **] problem
Sister with Bell's palsy
Brother is 83 and healthy
Mother had heart disease
Father died from pneumonia
No family history of malignancy
Physical Exam:
Upon admission:
General: Somnolent but arousable, oriented to person and [**Hospital 86**]
hospital, no acute distress
HEENT: Sclerae icteric, MM very dry, dried blood in posterior
OP, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Fast but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diminished BS at R base, no wheezes, rales, ronchi
Abdomen: soft, non-distended, hypoactive bowel sounds present,
+hepatomegaly, +RUQ TTP, no rebound/guarding
GU: foley with dark amber urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: R sided facial droop, tongue midline, PERRL, EOMI, unable
to further test CN. Strength 5/5 on left, [**3-20**] in RLE, RUE.
Patellar reflexes 0 bilaterally. Dysarthric. No clear asterixis.
Skin: hyperpigmented area noted over L medial calf. No spider
angiomata noted. Jaundiced.
At discharge: Patient expired.
Pertinent Results:
Labs:
[**2157-8-13**] 09:30PM BLOOD WBC-3.3* RBC-3.81* Hgb-10.9* Hct-33.2*
MCV-87# MCH-28.6# MCHC-32.8 RDW-16.2* Plt Ct-99*#
[**2157-8-13**] 09:30PM BLOOD Neuts-88* Bands-0 Lymphs-3* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2157-8-13**] 09:30PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-1+ Spheroc-1+ Target-1+
[**2157-8-14**] 04:02AM BLOOD PT-24.9* PTT-46.3* INR(PT)-2.4*
[**2157-8-13**] 09:30PM BLOOD PT-25.4* PTT-43.2* INR(PT)-2.4*
[**2157-8-14**] 06:24AM BLOOD FDP-10-40*
[**2157-8-14**] 04:02AM BLOOD Thrombn-16.3
[**2157-8-13**] 09:30PM BLOOD Fibrino-247
[**2157-8-14**] 04:02AM BLOOD ACA IgG-PND ACA IgM-PND
[**2157-8-14**] 04:02AM BLOOD Lupus-PND
[**2157-8-14**] 04:02AM BLOOD Glucose-65* UreaN-74* Creat-3.0* Na-143
K-4.8 Cl-114* HCO3-16* AnGap-18
[**2157-8-13**] 09:30PM BLOOD Glucose-72 UreaN-78* Creat-3.2*# Na-140
K-5.0 Cl-106 HCO3-19* AnGap-20
[**2157-8-14**] 04:02AM BLOOD ALT-93* AST-131* LD(LDH)-468* CK(CPK)-32*
AlkPhos-471* TotBili-14.0* DirBili-10.0* IndBili-4.0
[**2157-8-13**] 09:30PM BLOOD ALT-113* AST-150* LD(LDH)-474*
AlkPhos-612* TotBili-17.4* DirBili-14.6* IndBili-2.8
[**2157-8-14**] 04:02AM BLOOD TotProt-3.0* Albumin-1.8* Globuln-1.2*
Calcium-6.1* Phos-3.6 Mg-2.0 Iron-26*
[**2157-8-13**] 09:30PM BLOOD Calcium-7.4* Phos-4.0 Mg-2.4
[**2157-8-14**] 04:02AM BLOOD calTIBC-73* Hapto-91 Ferritn-9187*
TRF-56*
[**2157-8-14**] 04:02AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2157-8-14**] 04:02AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2157-8-14**] 04:02AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2157-8-14**] 04:02AM BLOOD PEP-NO SPECIFI
[**2157-8-14**] 04:02AM BLOOD tTG-IgA-PND
[**2157-8-14**] 04:02AM BLOOD HCV Ab-NEGATIVE
[**2157-8-13**] 09:53PM BLOOD Lactate-3.1*
Micro:
[**2157-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2157-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2157-8-14**] IMMUNOLOGY HCV VIRAL LOAD-FINAL
[**2157-8-14**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL
[**2157-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2157-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2157-8-14**] MRSA SCREEN MRSA SCREEN
Reports:
[**2157-8-14**] MRI/A head: 1. There is evidence of vascular flow in
both internal carotid arteries with mild narrowing of the distal
branches intracranially, possibly related with atherosclerotic
disease and more significant on the right middle cerebral
artery. The left vertebral artery is dominant. 2. The neck
vessels demonstrate mild bilateral narrowing of the cervical
carotid bifurcations, correlation with carotid ultrasound is
recommended if clinically warranted.
[**2157-8-14**] MRI spine: 1. Mild-to-moderate multilevel degenerative
changes throughout the cervical spine, more significant from
C2-C3 through C5-C6 levels. 2. No focal or diffuse lesions are
noted throughout the cervical spinal cord to indicate spinal
cord edema or cord expansion.
[**2157-8-14**] CXR: Interval placement of nasogastric tube, terminating
in the stomach. Heart size remains normal. Bilateral small
pleural effusions are partially layering on this semi-upright
radiograph and are accompanied basilar atelectasis, worse on the
left than the right. Remainder of the lungs is grossly clear.
[**2157-8-14**] abd u/s: 1. Patent hepatic veins and portal veins. 2.
Patent renal arteries and veins. 3. Small abdominal ascites and
right pleural effusion.
Brief Hospital Course:
77 yo male with previous CVA, recent admission for CN palsy and
weight loss with unrevealing initial workup who was transferred
from OSH after presenting with fever and malaise found to now
have rising bilirubin, [**Last Name (un) **], and recent CVA with residual
neurologic deficits. During his time at [**Hospital1 18**], he was found to
have right sided weakness and a right facial droop. His
neurologic status progressively declined over his course to a
severe clinical encephalopathy. His liver failure also
progressed during his stay. RUQ ultrasound did not identify a
cause. His acute renal failure followed his liver failure and
was thought to be secondary to this process. Based on the
pattern of his LFT's, his pancytopenia, his lymphadenopathy, and
hiw weight loss, this was thought to be most likely be a
malignant infiltrative process with rapid progression. His
clinical status was discussed with his family, and based on the
poor prognosis including neurologic recovery, his family opted
to make the patient CMO. The patient expired approximately 20
hours after this decision was made. Multiple lab tests from
[**Hospital1 18**] and pathology reports from the OSH are pending at the time
of death. The family requested an autopsy.
Medications on Admission:
Medications HOME:
Coumadin
Flomax 0.4mg daily
.
Medications TRANSFER:
Doxycycline 100mg IV Q12H
Pantoprazole 40mg IV Q12H
Gentamicin 100mg IV Q12H
Tamsulosin 0.4mg QPM
Senna 1 tab daily:PRN constipation
Reglan 10mg IV Q8H:PRN nausea
Melatonin 1mg QHS:PRN insomnia
Guaifenisin/robitussin 200mg PO Q6H:PRN cough
NS@100cc/hr
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4433
} | Medical Text: Admission Date: [**2172-11-30**] Discharge Date:
Date of Birth: [**2109-12-21**] Sex: M
Service: CCU
CHIEF COMPLAINT: GI bleed.
HISTORY OF PRESENT ILLNESS: This is a 62 year old white male
with an extensive past medical history significant for
coronary artery disease requiring coronary artery bypass
graft, history of inferior myocardial infarction, status post
St. Jude valve for mitral valve prolapse in [**2169**], AICD for
ventricular tachycardia, CHF with EF of 25%, history of CVA,
history of ulcerative colitis, diverticulitis, abdominal
aortic aneurysm, chronic renal insufficiency, occluded left
RA, peripheral vascular disease, history of recent lower GI
bleed. Lower GI bleed occurred in [**2172-10-8**] when during
colonoscopy it was found that he had a cecal arteriovenous
malformation. He had been recently admitted to [**Hospital1 346**] for interrogation of his AICD. He
most recently had a lower GI bleed treated at [**Hospital6 3426**]. He was readmitted to [**Hospital6 33**] on
[**11-28**] for pulmonary edema. He was diuresed and his
symptoms resolved. However, during that admission he
developed dark diarrhea with a slow drop in his hematocrit.
There he had two negative CKs and troponins, but he was sent
to [**Hospital1 69**] for further workup of
his GI bleed and further treatment. At [**Hospital1 190**] the patient initially had no complaints. He
was given two units of FFP and then was given a bowel prep
with GoLYTELY. While receiving GoLYTELY, he developed chest
pain on his way to the bedside commode. Chest pain resolved
with two sublingual nitroglycerin and IV metoprolol. He also
had brown reddish appearance to his bowel movements. He had
another episode of [**8-17**] chest pain without radiation to his
neck. It did not resolve initially with two sublingual
nitroglycerin. However, he ruled out for coronary ischemia.
He received 81 mg of aspirin and 5 mg of IV metoprolol. He
also complained of headache and flushing.
PAST MEDICAL HISTORY: Coronary artery disease status post
inferior MI in [**2147**], status post coronary artery bypass graft
times two in [**2169**]. CABG involved LIMA to LAD and saphenous
vein graft to posterior descending artery. Mitral valve
replacement with St. Jude valve in [**2169**]. Ventricular
tachycardia status post dual chamber AICD in [**2167**] for
ventricular tachycardia and bradycardia. History of
inducible VT with old inferior scars. Status post multiple
admissions. CHF with EF of 25%. Epilepsy. Stroke involving
left middle cerebral artery. Diverticulitis. Benign
prostatic hypertrophy status post TURP. History of gastritis
H.pylori positive. Cholelithiasis. Ulcerative colitis
diagnosed in [**2128**]. Abdominal aortic aneurysm which is 3 to
3.5 mm in diameter. Status post appendectomy in [**2120**].
Occluded left renal artery most likely with chronic renal
insufficiency with creatinine of 2.5 to 3. Peripheral
vascular disease. Lower GI bleed which last occurred in
[**2172-10-8**]. At that time he was found to have cecal
arteriovenous malformation. He had two polyps removed. He
also had diverticulitis.
ALLERGIES: ACE inhibitor which causes angioedema. Codeine
and shellfish which cause hives. Contrast dye and iodine to
which he also has reactions.
MEDICATIONS: Hydralazine 75 mg p.o. t.i.d., amiodarone
200 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Klonopin 0.5 mg
p.o. b.i.d., Protonix 40 mg p.o. q.d., folate 1 mg p.o. q.d.,
Mysoline 250 mg p.o. q.d., Colace 100 mg p.o. b.i.d.,
carvedilol 0.125 mg p.o. b.i.d., furosemide 80 mg p.o.
b.i.d., multivitamin, Norvasc 2.5 mg q.d., Imdur 30 mg p.o.
q.d. which had been discontinued because of headache,
Aldactone 25 mg p.o. q.d. which was also discontinued.
PHYSICAL EXAMINATION: Heart rate was 78, blood pressure
162/76, sating 97% on 2 liters, respiratory rate 20. In
general, he was in moderate distress with chest pain, but
alert and oriented. Pupils were equal, round and reactive to
light. Extraocular movements were intact. Moist mucous
membranes. Oropharynx was clear. Tongue was midline. Heart
regular rate and rhythm, S1 mechanical sound above apex, 2/6
systolic murmur without radiation. Lungs were limited to the
anterior. He was found to have crackles. Abdomen was soft,
nontender, nondistended with positive bowel sounds.
Extremities had 2 to 3+ peripheral edema, warm, no cyanosis
or clubbing. Dorsalis pedis pulse was palpable.
LABORATORY DATA: White count was 8.8, 82.5 neutrophils, 10
lymphocytes, 5 monocytes, 2 eosinophils, 5 basophils,
hematocrit 24.9, platelets 127. Sodium was 141, potassium
3.9, chloride 108, bicarb 24, BUN 46, creatinine 2.2, glucose
99. CK was 54. INR was 2.7, PTT 26.2. UA was yellow, clear
with specific gravity of 1.010, trace protein. EKG showed
normal sinus rhythm at 93 beats per minute with normal axis,
ST depressions and T wave inversions in aVL, 1, aVF, 2, V4,
V6. Positive for left ventricular hypertrophy by voltage
criteria. When he became chest pain free, he had less
prominent T wave inversions.
HOSPITAL COURSE: The patient was a 62 year old white male
with multiple medical problems who had a GI bleed complicated
by ischemic changes on his EKG.
1. Cardiac. His chest pain, along with the EKG changes, was
thought to be secondary to his anemia. He has a history of
chest pain with hematocrit decreases below 30. Consequently
the treatment in this situation was for blood transfusion.
However, because of his congestive heart failure and clinical
evidence of pulmonary edema, the blood transfusion would have
to be closely monitored. He required furosemide between each
unit. Because of his anemic situation, his antihypertensives
were held. His cardiac enzymes were cycled and were
negative. Troponin was 0.4. CKs were 43, 45 and 102. No
CKMB fractions were done on those CKs. Because of the
setting of his acute GI bleed, aspirin was held. The goal
was to keep his hematocrit above 30. On the second day of
admission he had chest pain after having hematochezia. He
had ST depressions on his EKG. At that time nitroglycerin
drip was started. He also received metoprolol IV, morphine
and aspirin. He was also diuresed with 40 mg of IV Lasix.
Because of his cardiac issues, he was continued on
nitroglycerin drip along with metoprolol 12.5 mg p.o. b.i.d.
He was also started on hydralazine 50 mg p.o. t.i.d. for
afterload reduction. His INR had initially been elevated at
2.6. Consequently because of his GI bleed, it was decided to
discontinue Coumadin. Heparin was then started. However,
after he had hematochezia associated with chest pain, heparin
was also discontinued. He had been actually hypertensive
with blood pressure between 140s and 200s despite probable
bleeding from the GI tract. Hydralazine was continued and
increased eventually to 75 mg p.o. b.i.d.
He had colonoscopy done on [**2172-12-2**]. Thereafter he
was started on heparin and aspirin. Metoprolol was increased
to 25 mg p.o. b.i.d. Because he had been placed on
carvedilol as an outpatient, he was then switched over to
carvedilol 12.5 mg p.o. b.i.d. It was then increased to
25 mg p.o. b.i.d. However, these events occurred after his
colonoscopy. He was also started on amlodipine and Imdur.
Imdur was started at 30 mg p.o. q.d. Norvasc was started at
10 mg p.o. q.d. He continued to be diuresed because of his
congestive heart failure. He required 80 mg IV b.i.d. This
was transitioned to 80 mg p.o. b.i.d. which was his dose
taken at home. Daily weights were measured. His edema
improved gradually over time. He was transferred to the
floor on [**2172-12-3**]. He had some nonsustained v-tach.
However, his AICD was interrogated and it was found to be
working well. He was continued on heparin for his mitral
valve replacement. It was debated whether to start low
molecular weight heparin. However, it was decided that he
would be started on Coumadin. GI Fellow was consulted about
this. They felt that the risk of bleeding would be low after
having intervention so subsequently he was started on
Coumadin 5 mg p.o. on [**2172-12-6**]. He will need to be
continued on Coumadin with a goal INR of 2 to 3. Heparin
will be continued until his INR is therapeutic. There was
some discussion whether he needed cardiac catheterization.
Because of his GI bleed issues and his anemia, cardiac
catheterization was deferred on this admission. It will need
to be reconsidered as an outpatient.
2. GI. The patient had multiple episodes of hematochezia.
GI service was consulted and recommended colonoscopy.
Because of his history of cecal AVM, it was felt that his new
bleed was also related to cecal AVM. He had bowel movements
on [**2172-12-1**]. At that time a nuclear medicine scan
was determined to be most effective in localizing the bleed.
It showed active bleeding at the cecum. Because of his
anemia he was transfused multiple units of blood. GI service
recommended discontinuing anticoagulants that were on board.
During the procedure he was found to have a single large
angiectasia that was not bleeding in the cecum. BICAP
electrocautery was applied for hemostasis successfully. Two
nonbleeding polyps with benign appearance and ranging in size
from 3 mm to 6 mm were found in the descending colon and
rectum. Nonbleeding grade 2 internal hemorrhoids were noted.
Diverticula was seen in the proximal sigmoid colon. However,
none of the polyps were removed. Anticoagulation was held
for 24 hours after the procedure. Thereafter heparin was
started. The patient had a bowel movement on [**12-5**] and
[**12-6**]. Both bowel movements were guaiac negative. It
was thought that his GI bleed was under control.
Consequently anticoagulation would be acceptable.
3. The patient has chronic renal insufficiency. His
creatinine actually increased from 2.2 to 2.5 to 2.6. He may
have a renal azotemia picture. However, he has been
receiving large quantities of furosemide. His creatinine was
monitored. Magnesium and potassium were repleted as
necessary.
4. Heme. The patient was anemic and required multiple units
of blood. However, once he no longer had hematochezia his
hematocrit remained stable.
FOLLOWUP: The patient was originally at [**Hospital6 3426**]. Because of the proximity to his home, he can
possibly be transferred back to the TCU at [**Hospital6 3426**]. Physical therapy has seen him and recommended
rehab for him. He will need followup with cardiology and his
primary care physician. [**Name10 (NameIs) **] will most likely need followup in
two weeks.
DISCHARGE MEDICATIONS:
1. Lasix or furosemide 80 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Coumadin 5 mg p.o. q.d. (subject to change).
4. Heparin adjusted to PTT.
5. Aspirin 81 mg p.o. q.d.
6. Carvedilol 25 mg p.o. b.i.d.
7. Clonazepam 0.5 to 1 mg p.o. b.i.d.
8. Serax 15 mg p.o. q.h.s.
9. Tylenol 325 mg p.o. q.four to six hours.
10. Imdur XR 30 mg p.o. q.d.
11. Potassium chloride 40 mEq p.o. q.d.
12. Norvasc 10 mg p.o. q.d.
13. Hydralazine 75 mg p.o. t.i.d.
14. Levofloxacin 250 mg p.o. q.o.d. to be discontinued on
[**2172-12-6**].
CONDITION ON DISCHARGE: Guarded, but stable.
DISCHARGE STATUS: To be discharged to [**Hospital6 33**].
DISCHARGE DIAGNOSES:
1. Demand ischemia.
2. Arteriovenous malformation in the cecum.
3. CHF.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2172-12-6**] 13:03
T: [**2172-12-6**] 13:08
JOB#: [**Job Number 34300**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4434
} | Medical Text: Admission Date: [**2185-11-6**] Discharge Date: [**2185-11-11**]
Date of Birth: [**2113-11-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Iodine; Iodine Containing / Darvocet-N
100
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
ERCP ([**2185-11-7**])
PICC line placement ([**2185-11-10**])
History of Present Illness:
Ms. [**Known lastname 6357**] is a 71F with stage 4 pancreatic head cancer s/p
biliary stenting [**10/2185**] presenting with fevers at home. She
reports that otherwise she felt OK, her ROS is only notable for
one episode of vomiting yesterday. She denies any chills, night
sweats, abdominal pain, increase in frequency of stools, change
in skin color, confusion, or increased pruritis. She also denies
any new cough, dysuria, frequency or polyuria.
.
In the ED presenting vitals were T=98.8-102.5, BP=130/57, HR=83,
RR=20, 96% on room air. Notably, she had some episodes of SVT in
the ED to 150s, with associated hypotension to the 70s/50s.
These episodes reverted spontaneously within ~30seconds before
any treatments or EKGs could be initiated Her exam was notable
for RUQ tenderness. Laboratory data was notable for an increase
in her transaminases and alkaline phosphatase. Her Tbili was at
baseline, her lactate was 1.7, and she did not have a
leukocytosis. Urinalysis was negative, blood and urine cultures
were sent. A RUQ ultrasound showed expected pneumobilia with
pancreatic ductal dilation. A CT abdomen and pelvis showed
proper stent placement with biliarly ductal dilation, and
incidental cecal thickening. ERCP fellow was made aware of the
admission and recommended an ERCP tomorrow. Renal and cardiology
were asked to see the patient first thing in the AM prior to
this for HD and evaluation. She was given 4.5g of unasyn and 1g
of tylenol.
Past Medical History:
1. Stage four pancreatic cancer: Newly diagnosed in 10/[**2184**]. S/p
biliarly stent on [**2185-10-5**]. Oncologist is Dr. [**Last Name (STitle) **]. Not a
surgical candidate, and may have liver metastases. Has seen [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 4149**] in palliative care, however, no decisions have been made
yet with regard to hospice care. Per [**2185-11-3**] note from Dr.
[**Last Name (STitle) **], the patient has decided to not proceed with
chemotherapy and concentrate on quality of life.
2. AVNRT: Managed with beta blocker therapy only per cardiology
consultation given poor prognosis of other co-morbidities. Has
syncopized in the past secondary to this.
3. HTN
4. Type 2 Diabetes Mellitus
5. ESRD on HD MWF: Nephrologist is Dr. [**Last Name (STitle) **]
6. Chronic systolic and diastolic CHF
7. H/o retinal detachment
8. Hyperlipidemia
Social History:
Never smoked, no etoh in 30+ years, no tobacco; lives at home
independently although her daughter has been staying with her
since her discharge from the hospital.
Family History:
Brother with pancreatic cancer
Physical Exam:
VITAL SIGNS: T 98.8, 71, 136/41, 96% RA
GENERAL: NAD, lying in bed in bed.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. mild
icterus. Surgical pupils BL. EOMI, OP clear.
CARDIAC: Regular rate and rhythm. Normal S1, S2. II/VI
holosystolic murmur loudest at axilla.
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: Non tender/non distended, hyperactive bowel sounds.
EXTREMITIES: No edema or calf pain, 2+ DP pulses. AV fistula
with bruit on left arm
SKIN: No obvious jaundice
PSYCH: Listens and responds to questions appropriately, pleasant
CN intact. 5/5 strength.
Pertinent Results:
PERTINENT LABORATORY DATA:
[**2185-11-6**] 3:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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.
Tigecycline = 0.25 MCG/ML, SENSITIVE , Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2185-11-7**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2185-11-7**] AT 0500.
GRAM NEGATIVE ROD(S).
ON ADMISSION:
ALT(SGPT)-331* AST(SGOT)-753* CK(CPK)-25* ALK PHOS-729* TOT
BILI-2.5* DIR BILI-1.6* INDIR BIL-0.9
GLUCOSE-221* UREA N-34* CREAT-7.2* SODIUM-139 POTASSIUM-3.2*
CHLORIDE-95* TOTAL CO2-32 ANION GAP-15
WBC-5.1 RBC-3.29* HGB-9.7* HCT-29.6* MCV-90 MCH-29.6 MCHC-32.9
RDW-17.0*
PT-12.7 PTT-23.5 INR(PT)-1.1
CHEST RADIOGRAPH, AP ([**2185-11-6**]): Low lung volumes are present.
The heart is mildly enlarged, unchanged. The aorta is unfolded
with aortic knob calcifications again demonstrated. There is
accentuation of the pulmonary vascular markings with crowding of
vascular structures, likely due to low lung volumes. Lungs are
grossly clear without focal consolidation, pleural effusions, or
pneumothorax. Osseous structures are unremarkable. Chronic
thickening of the left pleura is again noted.
CT ABDOMEN/PELVIS WITHOUT CONTRAST ([**2185-11-6**]): 1. Known mass in
the head of the pancreas is suboptimally evaluated in the
absence of IV contrast. Stent in expected location of the distal
common bile duct is probably patent, given presence of
pneumobilia. Mild biliary ductal dilatation. Adjacent duodenal
wall thickening may be due to underdistention, however,
inflammatory changes and/or tumor involvement is not excluded.
2. Cecal wall thickening is nonspecific and could be due to
inflammatory or infectious reasons. 3. Unchanged splenic
lesions. Stable appearance of the prominent left adrenal gland.
ABDOMINAL ULTRASOUND ([**2185-11-6**]): 1. Redemonstration of a known
pancreatic head mass with distal pancreatic atrophy and
pancreatic duct dilatation. 2. CBD stent not visualized,
however, presence of pneumobilia suggests patency of the stent.
3. Mild biliary ductal dilatation. Left lobe hepatic hyperechoic
lesion measures slightly larger today, and may be due the
technical reasons; this probably represents hemangioma, however,
a metastatic lesion not excluded in the setting of malignancy.
ERCP ([**2185-11-7**]): Eight intraprocedural spot radiographs of the
right upper quadrant from an ERCP show a pre-existing metallic
stent in the common bile duct. Subsequent images show
cannulation and opacification of the common bile duct with a
mild diffuse dilatation. Irregular filling defects are seen in
the common bile duct during its course through the metallic
stent. There are no other filling defects and there are no
strictures. Further details can be found in the ERCP report in
the patient's online medical record.
TTE ([**2185-11-10**]): The left atrial volume is markedly increased
(>32ml/m2). The interatrial septum is aneurysmal. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
mid inferior and inferolateral segments. 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 regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
No mass or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No vegetation, abscess or significant valvular
regurgitation seen. Moderate symmetric LVH with mild focal LV
systolic dysfunction. Biatrial enlargement.
CHEST RADIOGRAPH ([**2185-11-9**]): In comparison with the study of
[**11-6**], there has been placement of a right subclavian PICC line
that extends to the lower portion of the SVC. No evidence of
acute pneumonia or other cardiopulmonary abnormality.
Brief Hospital Course:
71 year old female with stage 4 pancreatic cancer presented with
fevers, vomiting, and abdominal pain on [**2185-11-6**].
Hospital course was as follows:
1. Bacteremia: On admission, patient was febrile to 102.5 found
to have RUQ tenderness. Did not appear jaundiced and bilirubin
was elevated but below baseline. Given known pancreatic head
mass and evidence of ductal dilatation on CT, concern for
ascending cholangitis. Blood cultures ([**12-1**] set) grew out GNR
within first 24 hours. Patient reportedly received Unasyn in
emergency department; antibiotic regimen was changed to
ciprofloxacin and Flagyl given reported history of allergy to
penicillins in past. On day 1 of admission, patient underwent
ERCP with debris extraction from major papilla stent. She
continued to be febrile post-procedure. Sensitivities revealed E
coli sensitive to only Zosyn; further antibiotic sensitivities
are pending. Given history of pencillin allergy (anaphylaxis) in
[**2174**] and unclear history regarding whether patient has received
penicillins since that time, patient was transferred to MICU for
pencillin desensitization. Zosyn desensitization was completed
in MICU with decreased beta-blocker dosing (beta-blockers lower
threshold for anaphylaxis reaction). On readmission to medicine
floor, antibiotic regimen was changed to meropenem given
identification of E coli as an extended-spectrum beta-lactamase
(ESBL) producer. Patient tolerated therapy well. TTE was
conducted to assess for seeding on valve; no vegetations were
seen. PICC line was placed on [**2185-11-10**]. Antibiotic course to
continue for total 14 days.
2. Pancreatic cancer, stage 4: The patient is no longer a
surgical candidate, nor would she benefit from chemotherapy, and
has decided not to go forward with aggressive management.
Palliative care was contact[**Name (NI) **] during admission, and patient
elected to have home hospice with continuation of hemodialysis
and antibiotics.
3. AVNRT: In emergency department, patient was noted to be
tachycardic with concurrent hypotension. Episodes were
short-lived (~30 seconds). On floor patient with stable vital
signs; on review of telemetry patient had few episodes of sinus
tachycardia to 150s. Home beta-blocker regimen was changed from
metoprolol tartate 150mg PO daily to 75mg PO BID. Cardiology was
consulted in emergency department; on floor recommended rate
control. On day 1 of admission patient triggered for tachycardia
to 130s; by EKG, she was found to be in atrial fibrillation with
RVR. Patient received metoprolol 5mg IV x4, diltiazem 10mg IV
x1, metoprolol 50mg PO, and diltiazem 30mg PO with improvement
in heart rate. For remainder of hospital course heart rate
well-maintained with metoprolol and diltiazem PO.
4. ESRD: Continued MWF HD sessions, Nephrocaps, and Sevelamer.
Nephrology involved.
5. DM: Held glipizide. On sliding scale insulin while inpatient.
**CODE STATUS: DNR/DNI, confirmed with patient
Medications on Admission:
AMLODIPINE 10mg daily
Nephrocaps
GLIPIZIDE 2.5mg daily
HYDROXYLINE 25mg daily
METOPROLOL TARTRATE 150mg daily
SEVELAMER 800mg daily
Discharge Medications:
1. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: 3-5 MLs
Intravenous Daily and PRN as needed for line flush.
Disp:*2 week supply* Refills:*0*
7. Saline Flush 0.9 % Syringe Sig: [**4-9**] Injection Daily and PRN
as needed for line flush.
Disp:*2 week supply* Refills:*0*
8. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 11 days.
Disp:*11 Recon Soln(s)* Refills:*0*
9. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
11. Morphine 15 mg Tablet Sig: AS DIRECTED Tablet PO every four
(4) hours as needed for pain: Take [**12-1**] to 1 tablet every 4 hours
as needed for pain. Please be aware this medication causes
drowsiness. Do not drive or operate any equipment or machinery
while taking. Hold for respirations < 10/minute or oversedation.
Disp:*180 Tablet(s)* Refills:*0*
12. IV Morphine Instructions
Please continue to take
Morphine Sulfate
1-2 mg IV Q4H:PRN
for pain relief
Hold for oversedation
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
- Ascending cholangitis
- E. coli bacteremia
- Penicillin desensitization
Secondary:
- AV nodal re-entrant tachycardia
- End stage renal disease, on hemodialysis
Discharge Condition:
Ambulatory. Hemodynamically stable.
Discharge Instructions:
You were admitted on [**2185-11-6**] with abdominal pain and a
fever. During your hospitalization, you were found to have
bacteria in your blood, likely coming from your abdomen. You
underwent ERCP, a procedure to visualize that stent that was
placed in your bile duct; this area was cleaned. You also
received IV antibiotics; this required a brief stay in the ICU
to allow you to take penicillins given that you have a pencillin
allergy. You had a PICC line placed to allow for a total 14 day
course of IV antibiotics.
Your medication regimen has changed. Please review the
medication list closely. Changes include:
- Adding diltiazem (by mouth), a medication to help control your
heart rhythm
- Adding meropenem (by IV), an antibiotic
- Stopping amlodipine
- Taking metoprolol at a different dose three times daily rather
than at the current dose once daily.
During the hospital course you and your family had discussions
regarding your care with the palliative care team. A hospice
organization will be working with you at home.
Please be sure to follow-up with your appointments as listed
below.
Please call your physician or return to the emergency department
if you have any concerns. The hospice organization will work
with you and your family to make you comfortable at home.
Followup Instructions:
Dr. [**Name (NI) 10944**]
[**2185-11-15**] at 1:10pm
[**Hospital3 4262**]
Phone: ([**Telephone/Fax (1) 8417**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. (ophthalmology)
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2185-11-15**] 1:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD
Phone:[**0-0-**] Date/Time:[**2185-12-15**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] (oncology)
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2185-12-15**] 2:00
Completed by:[**2185-11-16**]
ICD9 Codes: 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4435
} | Medical Text: Admission Date: [**2167-6-2**] Discharge Date: [**2167-6-5**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female with history of COPD, IPF, pulmonary hypertension
(60-67) on 5 L by NC home O2 who presented to her PCP on the day
of admission with a 1 week h/o increased dyspnea on exertion,
generalized fatigue. She went to her PCP and CXR ordered;
showed RLL pneumonia and PCP told pt to go to ED. In ED sats in
low 90's on 5 L but had desats into the 80's, pO2 of 49 on ABG.
.
She admits to having a nonproductive, chronic cough with no
recent change. She also has had intermittent left upper back
and chest wall pain at the site of old rib fractures. No
fevers, dizziness, abdominal pain, N/V, diarrhea, dysuria,
edema.
Past Medical History:
COPD
Idiopathic pulmonary fibrosis
Pulmonary hypertension
CAD s/p MI and stent to LCx
Hypertension
Osteoporosis
Renal Artery Stenosis s/p stent to R renal artery
CHF
Hyperlipidemia
GERD
Fe deficiency Anemia
s/p lap chole
hx MRSA pna
mesenteric ischemia
s/p L shoulder hemiarthroplasty
h/o fall with rib fractures
patent foramen ovale
Social History:
currently living in a [**Hospital3 **] facility. +tobacco in
past and quit 20 years ago; no drugs; occasional ETOH; retired
homemaker. Widowed.
Family History:
twin sister with IPF.
Physical Exam:
VS- 98.2 82 152/55 20 92% Bipap 5/0
Gen - AOX3, speaking full sentences, comfortable
HEENT - PERLA, cataracts bilaterally, anicteric
Heart - RRR, 3/6 M TR
Lungs - Dry hoarse crackles bilaterally, no wheezes
Abdomen - Soft, NT, ND + BS
Ext - No C/C/E, +2 d. pedis RLE, +1 d. pedis LLE
Skin - Multiple ecchymoses, easy bruising
Neuro - Grossly intact
Pertinent Results:
[**2167-6-2**] WBC-10.0 HGB-10.8* HCT-33.0* MCV-70* RDW-16.7* PLT-119
[**2167-6-2**] NEUTS-84.2* LYMPHS-9.7* MONOS-1.9* EOS-3.9 BASOS-0.2
[**2167-6-2**] GLUCOSE-135* UREA N-36* CREAT-1.8* SODIUM-137
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
Cardiac enzymes: negative
.
[**2167-6-2**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2167-6-2**] URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0
.
ECG: sinus, 90 bpm, normal axis, <[**Known lastname 4793**] depressions V5-V6.
Qwave II, aVF.
.
CXR ([**6-2**]): right lower lobe pneumonia, old emphysematous
changes
.
rib XR ([**6-2**]): At the site of the patient's maximal tenderness,
there are multiple deformities of the ribs that correlate with
rib fractures seen on the prior chest CT of [**2167-2-5**].
Brief Hospital Course:
Assessment and Plan:
Ms. [**Known lastname **]. [**Known lastname **] is a 77 yo female with severe baseline lung
disease (COPD and IPF) requiring home O2, presenting with
respiratory distress and pneumonia.
.
# COPD/IPF exacerbation: She has a history of COPD, IPF,
pulmonary hypertension, PFO. She has baseline DOE on 5L oxygen
at home ([**Hospital3 **]). Because of hypoxemia to 80%, she was
admitted to MICU. She was placed on bipap and was never
intubated. She eventually required CPAP only at night with 5-7
L by NC during the day. She received steroids (IV to PO) and
nebulizer treatments. The patient stated her wishes to be
DNR/DNI. She will be discharged on a prednisone taper. A bipap
machine for home was also arranged for the patient where she
will use at setting of [**4-10**]. Nasal saline also helped the
patient with dryness and bleeding from her nose due to oxygen
flow. She will continue her regular medications and inhalers at
home. She was also prescribed low dose fentanyl lozenges for
use as outpatient when preparing for exertion to decrease pain
and exertion. She will followup with Dr. [**Last Name (STitle) 217**]
regarding the effectiveness of these.
.
# Community acquired pneumonia: She was initially placed on
vancomycin and levofloxacin. Only levofloxacin was continued
for a total course of 10 days. This was renally dosed (750 mg
every other day).
.
# Acute on chronic renal failure: Creatinine 1.8 on admission;
this decreased to baseline of 1.3 by discharge. Acute component
was most likely prerenal/dehydration. Medications were renally
dosed.
.
# Blood cultures: 1/4 bottles positive for GPCs in clusters
which were later identified as coag negative staph. Due to only
having 1/4 bottles and that it was SCN, it was treated as a
contaminant, and vancomycin was discontinued.
.
# Hypertension: She remained on Coreg, diltiazem, imdur. Lasix
initally held with ARF but then restarted.
.
# Back and chest wall pain: reproducible at site of previous rib
fractures. It seemed unlikely to be cardiac in origin and
enzymes were negative; ECG did not show ischemic changes. A
lidoderm patch was used in house and will be prescribed for the
patient as an outpatient, as it provided significant relief.
.
# CAD: ASA, Imdur, Vytorin, Coreg were continued. Acute MI was
ruled out.
Medications on Admission:
Alprazolam 0.25 mg
ASA 81 mg
Boniva 150 mg PO Qmonth
Coreg 3.125 mg PO BID
Diltiazem ER 180 mg PO QD
Colace
Lasix 40 mg PO Sun/Tues/Thurs/Sat
Imdur 60 mg PO QD
MVI
Nexium 40 mg PO QD
Zoloft 150 mg PO QD
Trazadone 50 mg PO QD
Vitamin D 50,000 units
Vytorin 10/40 mg PO QD
Discharge Medications:
1. Sleep oximetry
Overnight continuous O2 saturation monitoring for one night
2. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once
a day for 10 days: Sat [**6-6**]: take 4 pills. Sun [**6-7**] through
Tues [**6-9**]: take 3 pills daily. Wed [**6-10**] through Fri [**6-12**]:
take 2 pills daily. Sat [**6-13**] through Mon [**6-15**]: take one pill
daily.
Disp:*22 Tablet(s)* Refills:*0*
3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO every other day
for 3 doses: Take first pill Sat, [**6-6**]; then take one pill
every other day.
Disp:*3 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
10. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Bipap
Diagnosis: COPD
Settings [**4-10**]
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY PRN () as needed
for back pain: Place on painful area for 12 hours out of every
day as needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
15. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal
Q3H (every 3 hours) as needed for nasal dryness.
Disp:*1 bottle* Refills:*1*
19. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
20. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-9**] Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
21. Fentanyl Citrate 200 mcg Lozenge on a Handle Sig: One (1)
Buccal three times a day as needed for pain or in preparation
for exercise.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Pneumonia
Chronic obstructive pulmonary disease
Idiopathic Pulmonary Fibrosis
Hypoxemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for difficulty brathing and pneumonia. We
treated you with oxygen and antibiotics.
.
Use oxygen at home, 5-6 liters per minute during rest and during
exercise. You can use your humidifier as needed.
.
At nighttime you will be using your new bipap machine. This is
only for use during sleep. You will be instructed on how to
operate this machine.
.
You may resume your regular activity at your [**Hospital3 **]
facility, including walking to meals.
.
Please return to the hospital if you are having trouble
breathing or chest pain, or any new symptoms that you are
concerned about.
.
Please take all of your medications and keep all of your
appointments with your doctors.
Followup Instructions:
Please see you PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 7 to 10 days. Please
call ([**Telephone/Fax (1) 33678**] to make an appointment.
.
Other upcoming appointments:
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2167-7-21**] 1:00
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2167-11-10**] 10:30
.
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2167-11-10**] 10:30
.
You also have an appointment with Dr. [**Last Name (STitle) 217**] on [**2167-11-10**]
following your PFTs. Please call ([**Telephone/Fax (1) 96590**] if you would
like to see him sooner.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 412, 4019, 2724, 486, 5849, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4436
} | Medical Text: Admission Date: [**2168-8-8**] Discharge Date: [**2168-11-19**]
Date of Birth: [**2128-10-27**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Compazine
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
MEC chemotherapy followed by syngeneic transplant
Major Surgical or Invasive Procedure:
hickman placed [**8-10**]
intubation
intra-aortic balloon pump
History of Present Illness:
Patient is a 39 year old woman diagnosed with AML in [**2166-11-11**]
after presenting for a routine physical exam, CBC revealed white
count of 5300 with 40% blasts. Pt noted generalized fatigue at
that time. Patient found to have normal cytogenetics,
immunophenotyping revealed positive CD34; positive CD13, and
positive CD17. Patient underwent induction 7+3; 5+2 in [**Month (only) 404**]
of [**2166**], followed by three cycles of consolidation after which
she had a bone marrow biopsy with remission in early [**2166**].
Patient remained in remission until [**3-31**] at which time she was
found to have relapsed by bone marrow biopsy and underwent
reinduction 7+3/5+2(idarubicin and cytarabine). Patient was
planned to have synergeneic transplant (she has a twin
sister-however this is in the process of being confirmed), with
BU/CY containing regimen. She was admitted for a week in [**Month (only) 205**]
for neutropenic fevers, hickman was pulled, and patient was
treated with Daptomycin. Last bone marrow biopsy on [**7-27**] shows
relapsed AML, CD34/CD13 with 26% blast cells. CMV viral load on
[**7-27**] was + at 36.
.
Although her English is limited, patient states that she has
been feeling relatively well since her discharge. Uses ativan
to help control her nausea, has had occasional diarrhea with the
most recent episode this am, denies any blood in stool. She
reports feeling tired most of the time, but her appetite and
weight have been stable (she initially lost 5-10lbs after
chemo). She denies any fever/chills or night sweats. She notes
trouble sleeping, which often results in a headache the
following morning. She also reports some chest/substernal
"discomfort"-particularly in the am, but denies pain or SOB.
Patient notes increased anxiety with this hospitalization.
Past Medical History:
1) AML, diagnosed in [**10-29**].
(a) normal cytogenetics.
(b) positive CD34; positive CD13, and positive CD17.
(c) status post 7+3; status post 5+2 in [**2166-11-27**].
(d) bone marrow biopsy with remission in early [**2166**].
(e) she is status post HIDAC consolidation in [**2166-12-28**],
complicated by fever and neutropenia with no clear source with
an admission in [**2167-1-26**].
(f) status post HIDAC two on [**2167-1-26**] with mild
transaminitis (last dose held).
(g) She received her third and last cycle of HiDAC consolidation
in [**2167-2-26**].
2) Has noted heavy periods and was recently diagnosed with
fibroids.
Social History:
Patient is from [**Country 3992**] and has lived in the US for 13 years.
Formerly worked for an electric company. She is married with two
children. She denies use of alcohol or illicit drugs. She has
a sister with a human leukocyte antigen match in [**Country 3992**]. She
speaks Cantonese and some English.
Family History:
Non-contributory
Physical Exam:
VITALS: 103lbs/ 98.1/ 100/18/120/70 100% on RA
GEN:awake, alert, pleasant, speaks some english, thin but not
cachetic
HEENT:atraumatic, sclerae anicteric, no pharyngeal exudate but
some whitish coating on tongue. No ulcerations or lesions.
NECK:NO LAD, no JVD, no carotid bruits
SKIN:warm/dry/ no rashes, +ttp around old hickman site- no
edema/erythema
CV:tachy, nml S1/S2, + DP pulses strong bilaterally
LUNGS:CTA B/L
ABDOMEN:soft, nontender, no organomegaly, decreased BS
EXT:no C/C/E, normal muscle tone, 5/5 strength in all 4
extremities, symmetric
NEURO: CN II-XII relatively intact, A/O x3, no focal deficits
(transfer to ICU)
Vitals: T 96.0, BP 89/56, HR 130, RR 31, O2 sat 91% RA
Gen: lying in bed, intubated, awake
HEENT: allocepecia, anicteric, EOMI, PERRL, OP clear w/ MMM
Neck: + JVD to angle of jaw
CV: Tachycardic, reg s1/s2, could not appreciate M/R/G
Pulm: ventilated BS b/l
Abd: +BS, soft, NT, ND
Ext: warm, 2+ pitting edema extending to thighs and sacram b/l,
1+ pitting edema to mid-arm b/l, + DP pulses b/l
Pertinent Results:
Labs on admission:
GLUCOSE-98 UREA N-10 CREAT-0.4 SODIUM-140 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-28 ANION GAP-12 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-1.8
.
ALT(SGPT)-18 AST(SGOT)-18 LD(LDH)-158 ALK PHOS-44 TOT BILI-0.3
ALBUMIN-4.5
.
WBC-2.5* RBC-3.71* HGB-12.1 HCT-35.2* MCV-95 MCH-32.7* MCHC-34.5
RDW-14.9 NEUTS-22* BANDS-0 LYMPHS-63* MONOS-1* EOS-4 BASOS-0
ATYPS-5* METAS-0 MYELOS-0 BLASTS-5* HYPOCHROM-NORMAL
ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL
MICROCYT-NORMAL POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL
.
Labs on expiration:
WBC-8.6 RBC-3.14* Hgb-10.6* Hct-31.7* MCV-101* MCH-33.8*
MCHC-33.4 RDW-25.5* Plt Ct-20*
.
PT-15.9* PTT-74.5* INR(PT)-1.7
.
Glucose-108* UreaN-67* Creat-1.0 Na-131* K-4.5 Cl-91* HCO3-27
AnGap-18 Calcium-8.7 Phos-5.5* Mg-2.0
.
.
Imaging:
[**11-18**] PCXR: An endotracheal tube ends in satisfactory position 4
cm above the carina. An NG tube curls in the stomach. A
Swan-Ganz catheter from the inferior approach ends in the
proximal left pulmonary artery. Mild cardiomegaly is unchanged.
A small left effusion is stable. Opacity within the left lower
lobe and the peripheral right lung base is unchanged. No failure
or pneumothorax is seen.
IMPRESSION: Lines and tubes in satisfactory position. Opacity in
the left lower lobe and the right lateral lung base representing
possible pneumonia Vs. atelectasis are unchanged compared to
[**2168-11-17**].
.
[**11-11**] Cath: FINAL DIAGNOSIS:
1. Cardiogenic [**Month/Year (2) **] with vasodilatory [**Month/Year (2) **]
2. IABP insertion.
.
[**11-13**] RUQ US: There is a large right-sided pleural effusion.
Gallbladder is not distended. There is gallbladder wall
thickening. No gallstones are seen. There is possible sludge
within the gallbladder. There is no intra- or extra- hepatic
biliary ductal dilatation. Common duct measures 3-4 mm. Portal
vein appears patent on limited imaging.
IMPRESSION:
1. Large right-sided pleural effusion.
2. Gallbladder wall thickening without gallstones identified.
The appearance of the gallbladder is not significantly changed
compared to the exam of seven days prior. Causes of gallbladder
wall thickening include hypoalbuminemia, CHF, liver disease, and
other causes of third spacing. If there is continued clinical
concern for acalculous cholecystitis, HIDA scan may be performed
for further evaluation.
Brief Hospital Course:
39 year old female with relapsed AML, admitted for re-induction
followed by syngeneic/identical twin allogenic transplant.
Patient had been on BMT service for >2 months and was then
transferred to the MICU for CHF, including diuresis and
afterload reduction therapy initially with hydralazine changed
to ACE I (captopril). With these interventions, patient's weight
decreased from 130 -> 114 lbs. Course was c/b intermittent
episodes of hypotension (below baseline hypotension of SBP 80's
- 100's) and lightheadedness. Following stablization after
weight loss and transfer to the floor, patient had orthostasis,
continued total body edema and continued to complain of dry
mouth. Her cardiac managment is otherwise complicated by
continuous sinus tachycardia to 120-140's.
Patient was then transferred from the floor to [**Hospital Unit Name 196**] for
management of heart failure and diuresis. She diuresed well over
2 weeks however was still fluid overloaded. Patient underwent a
trial of nesiritide for diuresis while off captopril and then
lasix was added the regimen. On [**11-7**], patient diuresed well on
lasix with a slight elevation in creatinine to 1.6, but a new
anion gap was noted with a lactate of 7. Also, LFT's increased
without clear cause. On [**11-10**], patient become hypotensive to
60's overnight with worsening respiratory distress. Unclear
whether this was due to sepsis versus cardiogenic [**Month/Year (2) **].
Patient was subsequently transferred to the CCU and intubated
due to respiratory distress. A venous blood gas showed a pH of
7.14 and venous lactate of 13. At the time, patient's INR was 4
and her respiratory and hemodynamic status very tenous. Also,
with tricuspid vegetation and known endocarditis, it was thought
placing a swan would be high risk. As mentioned above, [**Hospital 228**]
hospital course also complicated by strep viridans endocarditis
with visible vegetations seen on most recent ECHO [**2168-10-19**].
Diagnosed in [**10-1**] treated with 10 days gentamicin and 4 weeks
ceftriaxone, generalized anasarca, persistent sinus tachycardia
with occasional [**Month/Day (1) 6059**], bilateral pleural effusions, acalculous
cholecystitis, portal vein thrombosis, DIC and hemorrhoids.
.
.
* AML - pt was started on syngeneic transplant protocol upon
admission on [**2168-8-8**]. Hickman was placed on [**8-10**]. Pt was
preconditioned with MEC. Of note patient had PPD/[**Female First Name (un) **]
placed. She had positive PPD 12 years ago and was treated for
six months - pt can't remember which drug. Patient's chest x-ray
was negative, no active symptoms now or during previous
chemotherapy. No intervention/treatment necessary at this time
after consulting with ID. On [**8-24**] pt was started on Allo
Bisulfan/Cytoxan protocol. She was continued on
Levofloxacin/Flagyl coverage. Pt also received a PICC line in
addition to her R double lumen Hickman. Attemtp to L sided
Hickman previously failed secondary to inability to advance the
catheter during IR. Pt tolerated transplant well and her ANC
gradually increased with resolution of neutropenia. Pt was
initially started on Acyclovir. She was also treated with
empiric Flucanazole. Acyclovir and fluconazole were to be
continued for 6 months after trasplant. At that time peripheral
blood did not reveal any blasts, and there was normal trilineage
maturation. Pt was believed to be in complete remission from
the AML, and did not required chronic blood product transfusion.
No further chemotherapy was planned in the near future. If her
AML relapsed, her prognosis will be poor. During her MICU stay,
there was no evidence of AML recurrence.
.
* Abdominal pain - The patient complained of right sided
abdominal pain of mild severity, worse with palpation, often
absent at rest, during her MICU stay. This was attributed to her
portal vein thrombosis initially, however patient described
early satiety. EGD was unremarkable (some linear gastritis
only), and not able to account for the patient's symptoms. The
patient was placed on a PPI. A CT w/ contrast on [**10-24**] revealed
contracted portal vein thrombosis, cecal wall thickening,
possibly secondary to ascites and a question of free air, which
was further discussed with radiology and determined to be most
likely in the appendix. However, no clear source for her
polymicrobial blood cultures was found. Per ID, she was
continued on her metronidazole for a 10 day course. She has
remained afebrile since.
.
* CP - patient intermittently complained of CP on several
occasions. Repeated EKGs showed no ST changes. Later in the
course they were significant for sinus tachycardia. Cardiac
enzymes were significant for troponin of 0.05 x 3, which was
stable and not trending up, ck-MB was negative. This was thought
to represent mild troponin leak secondary to demand ischemia
sometimes as could be expected in high catecholamine states that
accompanies severe sinus tachycardia. Repeat Echo also showed
worsening EF with global hypokinesis. Pt also had an increasing
pulmonary artery pressure. V/Q scan was normal and there was
only mild pulmonary edema on diagnostic studies. Patient had
periodic echocardiograms done showing progressively worse
systolic right and left sided function. An echo on [**9-27**], done
to evaluate interval changes prior to surgery for suspected
cholecystitis, showed worsened EF<20% and new vegetations on the
tricuspid valve and the chordae to the tricuspid valve.
Subsequent echos supported the data from the earlier echos
(EF<20% w/ marked TR). The patient did not complain of CP during
her MICU stay. However, on transfer to the BMT floor, she did
have several instances of chest pain without EKG changes. Her
cardiac enzymes were cycled once with negative CK, and CKMB, and
stable troponins. Her chest pain was thought to be secondary to
anxiety, often resolving with ativan, and sinus tachycardia, and
was treated with morphine and attempts at better rate control.
.
* CHF - her cardiomyopathy was new since her transplant as a
echo prior to transplant revealed normal systolic function. The
worsened heart function was believed to be secondary to cytoxan
as well as prior anthracycline. She had diffuse anasarca, due
to EF <20%, severe tricuspid regurgitation, as well as
malnutrition and low albumin with low oncotic pressure. She was
managed with lasix, metoprolol 12.5 PO TID, spironolactone 25mg
PO TID, and digoxin 0.125 mg PO every other day. It was unclear
if her cardiac function would improve. Patient's blood pressure
with diuresis was marginal and cardiology consult initially did
not believe there was room to add ACE-inhibitor, neither did
they believe that she would benefit from afterload reduction.
Patient's maximum weight was 130 lbs and she was diuresed to 123
lbs with lasix 20mg PO TID and more recently a lasix drip at
2mg/hr in the MICU. In addition, she had a thoracentesis of her
right sided pleural effusion with removal of 1L, and some
improvement of her dyspnea. Of note, she has not required
supplemental oxygen. Echos demonstrated EF<20% on multiple
occasions. She was overall fluid overloaded and responded
somewhat to diuresis in the MICU. She was transferred to the
floor for CHF optimization when she no longer required MICU
level care ([**10-20**]). On the floor, a CXR showed continued
failure, which was confirmed by a CT with contrast on [**10-24**].
She was actively diuresed with lasix 40 mg PO QD to 114 lbs,
with a consequent increase in her serum Cr from 0.8 to 1.4. A
repeat CXR on [**10-31**] showed marked improvement of her asymetric
pulmonary edema, though on exam, she continued to have [**11-29**]+ LE
edema L>R and ascites. She was also tried on carvedilol per
cardiology for rate control with a drop her SBP to the 70s.
Cardiology then recommended acebutalol for greater Beta 1
selectivity, but she also did not tolerate this with a drop in
SBP to 69, which returned to 85 after 150 cc IV bolus of NS.
Her digoxin was titrated to try to improve her rate control and
was set at alternating doses of 0.1875 and 0.25 with a resting
HR in the 120-130s. She was also started on captopril 6.25 mg
PO TID for afterload reduction and for her EF<20%. She was
subsequently transferred to cardiology ([**Hospital Unit Name 196**]) for further
cardiac management on [**2168-11-1**].
.
On cardiology service diuresis was attempted by placing patient
on nesiritide drip and supplementing with lasix. Patient
initially tolerated this well, was able to lose approximately 5
pounds of water weight. However, lasix was discontinued after 2
days due to elevated creatinine. After 1 week on nesiritide,
this also had to be discontinued due to hypotension and
development of other medical issues including elevated lactate.
Patient was then transferred to the intensive care unit for
further monitoring and treatment.
.
Due to severe hypotension which was thought to be secondary to
cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] intra-aortic balloon pump was placed and
milronone drip was initiated. Upon presentation to the CCU, the
patient was afebrile without white blood cell count or clear
souce of infection. However, repeat ECHO showed persistent
vegetations and TR. Patient also required vasopressin and
levophed to maintain her blood pressure. Attempts at weaning
either the balloon pump and vasopressin were unsuccessful.
Patient was continued on the balloon pump for 1 week without
ability to wean and so was it was subsequently discontinued.
Patient expired shortly after balloon pump removal.
.
*Sinus Tachycardia - Patient was also noted following her
chemotherapy to have sinus tachycardia, onset at same time as
her above CHF. Her heart rate stayed in the 120's-160's and was
also addressed on her transfer to the cardiology service. It
was believed that her sinus tachycardia was likely compensatory
for her poor ejection fraction with her CHF. A trial of
carvedilol and acebutelol was attempted prior to transfer to
cardiology, but was not tolerated due to hypotension. On
cardiology service a trial of 1mg IV lopressor was attempted
with the thought that if her blood pressure tolerated this and
her heart rate decreased an oral trial of lopressor could be
attempted. However, with the 1 mg IV lopressore, patient's
heart rate dropped into 80-90's and her systolic blood pressure
dropped to 50's-60's. Therefore no nodal [**Doctor Last Name 360**] was started for
her tachycardia.
.
* [**Name (NI) 6059**] - pt has been on telemetry during her stay. She had two
episodes of [**Name (NI) 6059**] lasting apptoximately 12 beats with a
background of sinus tachycardia ranging up to 150s. She has
been continued on metoprolol 12.5 mg PO TID. She may need
evaluation for ICD placement, as this may be related to her
cardiomyopathy. This did not come up again during her MICU stay
or stay on the BMT floor. While in the CCU, patient had
persistant atrial tachycardia. On [**11-14**], heart rate was in the
140's and was hypotensive with systolic in the 60's and MAP in
50's. Patient was shocked 100J to hemodynamically stable atrial
tachycardia. Digoxin was discontinued secondary to toxicity.
.
* Endocarditis - Multiple cultures including fungal and m.fufur
cultures were drawn but remained negative. In addition patient
completed an empiric 2 week course of daptomycin (given hx of
allergy to vancomycin), meropenem, and ambisome. However, a
repeat echo showed unchanged size of the vegetatations, and a
diagnosis of marantic endocarditis was suspected. If patient
develops a fever, infectious endocarditis once again has to be
considered and she needs to be broadly cultured including fungal
cultures. A subsequent echo showed worsening TR without note of
the vegetation on the echo dated [**10-19**]. The patient was tx'd w/
ceftriaxone 2g daily, beginning on [**10-16**] and will need 4 weeks
of treatment to be completed on [**2168-11-13**]. Follow up blood
cultures and ECHO should be done at that time to ensure
bacteremia and tricuspid vegetations have resolved.
- h/o strep viridans endocarditis, s/p 10 days gentamicin and
currently on CTX (started [**10-16**]) to complete a 4 week course,
[**11-7**] repeat ECHO show persistent vegetations on TR.
- discontinued CTX change to daptomycin/meropenum day 9
- dc'd caspofungin day 6
- pt grew 100K enterococcus in urine should be covered for VRE
with daptomycin
- pan-cultured, incl fungal, pulled PICC sent tip for culture
- apprec pulm recs, will send sputum cx
- US of abdomen consistent with volume overload -> HIDA given
persistently incr TB concerning for cholecystitis
- worsening skin breakdown at site of balloon cath sutures,
being covered with daptomycin
- f/u ID recs - appreciate input
.
# Elevated Lactate and AG: Pt noted to have elevated lactate to
6.57 on [**11-7**], AG = 18/19. Infectious work up did not yield any
results. Repeat lactates continued to rise, and on [**11-10**],
patient was noted to have a lactate of 13.9 and an anion gap of
25. During this time, patient was persistently hypotensive with
SBP in 60's. Therefore likely secondary to hypoperfusion.
Patient was transferred to ICU for further managment.
.
* Acute cholecystitis/Elevated LFTs - pt consistently had
tachycardia which was thought to possibly be related to an
occult infection. She began developing RUQ pain and US was done
suggestive of acute cholecysitis. Her transaminases were
elevated to the 200s, but the bilirubin was normal. While being
transported to W campus for surgery, her ECHO report came back
with worsening LV function and a vegetation on the TV. She was
admitted to the MICU after a cholecystostomy tube was placed by
IR. General A repeat US showed a decompressed gallbladder. Her
transaminases continued to rise above 1000, and a repeat
abdominal U/S and CT scan were done, showing a new partial
portal vein thrombus. Her transaminases then trended downward
and the patient left the MICU w/ unremarkable transaminases. On
the BMT floor, her transaminases remained unremarkable. On
transfer to cardiology, LFTs were noted to elevate again.
Hepatology was reconsulted and believed this rise was secondary
to hepatic congestion from right heart failure. Throughtout
remainder of time of cardiology service, LFTs began to normalize
except for her T. Bili and D. Bili which continued to rise.
.
* Portal vein thrombosis - patient was started on a heparin drip
and continued with a goal PTT 60-80. Her liver abdnormalities
resolved on the heparin drip. The patient accidentally
partially removed the cholecystostomy drain, her labs remained
stable as did the abdominal pain for the next few days and the
drain tube was discontinued. Repeat u/s showed consistently
decompressed gall bladder. The patient was continued on heparin
drip with plans to switch to lovenow injections for continued
anticoagulation. A repeat u/s showed persistent thrombus. The
heparin drip was d/c at the recommendation of the heme/onc
service for concern of HIT. Multiple HIT Ab tests were negative
and a serotoninin assay that was reported to be more sensitive
for HIT was negative. A CT on [**10-24**] showed a contracted portal
vein thrombosis. A RUQ ultrasound on [**2168-11-6**] demonstrated
resolution of her portal vein thrombosis.
.
* RUE swelling, labial swelling - the pt was noted to have a
swollen R arm. An US obtained while the pt was in the MICU
revealed no clot and was believed to be related to anasarca. In
addition, she had labial swelling R>L, concerning for abscess.
Fluid was aspirated and negative for infection. Nothing further.
.
* DIC - On transfer to the MICU the pt was felt to be in early
DIC, with increasing LFTs, decreased fibrinogen, increased LDH,
and decreasing platelets. She received 6 units of FFP and 1 bag
of cryo and serial DIC labs were followed, with improvement over
the time she was in the MICU. It was felt that the endocarditis
or sepsis were the most likely etiologies, although initial
blood cultures did not grow any organisms. The pt was maintained
on broad-spectrum antibiotics and antifungals with input from
ID. Her DIC resolved, but this was postulated as a possible
unifying diagnosis to explain the portal vein thrombosis. On
[**11-9**], her fibrinogen was noted to drop, and she was transfused
1 bag of cryoprecipitate.
.
* Hemorrhoids - On [**8-22**] she started complaining of hemorrhoidal
pain c/w large external hemorrhoids. Pt was intially put on
stool softeners and eventually made NPO with TPN in order to
minimized potential infectious exposure in the rectal area. She
was empirically covered for colon flora with Levoquin and
Flagyl. Morphine was used for pain control. Pt stool was C.
Diff negative x 3. Although she did have intermittent diarrhea
that was controlled with Immodium.
.
Dispo - pt transferred from to cardiology for optimization of
her cardiac regimen. Pt then transferred to the unit due to
persistent hypotension, elevated anion gap, elevated lactate for
further management.
.
Patient then transferred from cardiology floor to cardiac
intensive care unit for persistent sinus tachycardia and
hypotension. Due to persistent hypotension refractory to fluid
boluses and pressors, an intra-aortic balloon pump was placed in
the setting of cardiogenic [**Month/Year (2) **] +/- septic [**Month/Year (2) **].
.
##CARDIAC
#ischemia: no known history of prior cath's.
.
#pump: nonischemic cardiomyopathy/CHF: EF ~10%, likely secondary
to chemo toxicity vs [**12-30**] persistant tachycardia. Given
improvement with IABP, on milrinone, no WBC, afebrile, no clear
source of infection likely in cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] also have
an element of septic [**First Name3 (LF) **]. Repeat ECHO show persistent
vegetations on TR.
- attempted to wean IABP however CI 1.7 on 1:2
- cont max doses of vasopressin, milronine and levophed
- keep at goal CVP 16-18
- need to consider insensible losses
- total body anasarca, likely related to her low EF. Also likely
contributed to by her low Alb (last value = 2.9).
.
#rhythm: persistant atrial tachycardia. 12/19 HR 140's
hypotensive syst 60's MAP 50's required 100J [**First Name3 (LF) **] to stable
atrial tach.
- dc digoxin given toxicity
- monitor on telemetry
.
#. ID:
- h/o strep viridans endocarditis, s/p 10 days gentamicin and
currently on CTX (started [**10-16**]) to complete a 4 week course,
[**11-7**] repeat ECHO show persistent vegetations on TR.
- discontinued CTX change to daptomycin/meropenum day 9
- dc'd caspofungin day 6
- pt grew 100K enterococcus in urine should be covered for VRE
with daptomycin
- pan-cultured, incl fungal, pulled PICC sent tip for culture
- apprec pulm recs, will send sputum cx
- US of abdomen consistent with volume overload -> HIDA given
persistently incr TB concerning for cholecystitis
- worsening skin breakdown at site of balloon cath sutures,
being covered with daptomycin
- f/u ID recs - appreciate input
.
# Elevated LFTs/INR: h/o possible acalculous cholecystitis
treated successfully with transcutaneous drain, now s/p drain
removal. [**11-5**] LFTs trending up again. ? [**12-30**] hepatic congestion
from R heart failure vs repeat acalculous cholecystitis vs GVHD
vs VOD vs hepatic candidiasis. Pt clinically asymptomatic. RUQ
U/S ([**11-6**]) - no liver or GB abnormalities, patent portal vein
(previously thrombosed). Hepatology consulted, believe elevated
LFTs [**12-30**] hepatic congestion from R heart failure.
- [**Month/Day (2) 3539**] gradually elevated from originally event [**11-3**], per liver
likely lag in [**Last Name (LF) 3539**], [**First Name3 (LF) 18003**] bili unmeasurable
- would like to HIDA scan to assess for recurrence of acalculous
cholecystitis however need to remove balloon pump and no
portable available
- Cont heparin for balloon pump
- trend LFTs daily
- daily fibrinogen if <100 give cryo
- heparin [**Hospital1 **]
.
#. Thrombocytopenia/DIC: Noted earlier in hospital admission of
unknown etiology - all HIT ab's negative x multiple times
inlcuding more sensitive HIT test (serotonin assay). Pt was
stabilized with stable Plts 50's-60's now stable in 20's.
- apprec heme/onc recs, started heparin drip for IABP.
- follow plat count, tranfuse if spontaneously bleeds or
plat<10K.
- consider BM bx
.
# Skin breakdown/blister: likely [**12-30**] to anasarca and severe
fluid overload
- wound care
- apprec plastics recs
- apprec derm
.
#. Respiratory distress: intubated [**12-30**] unresponsiveness and
hypoxia.
- plan for extubation today allow pt to speak with family
.
#. AML: currently without evidence of recurrence of disease
however in setting of new thrombocytopenia may benefit from BM
bx
- concerning nucleated RBCs, ?recurrence
- monitor CBC with diff daily to eval for blasts, atyps, etc
- cont acyclovir, renally dosed
- apprec heme/onc recs
.
FEN: Holding additional fluids and concentrating fluids given
anasarca
- cont TF as tolerated
- electrolyte repletion
- cont anti-emetics
.
#. Access: left groin triple lumen, IABP placed right femoral
vein.
.
#. PPX: Anzemet/compazine for nausea, on IV heparin
.
#. Communication: [**Name (NI) **] [**Name (NI) **] (husband) [**Telephone/Fax (1) 54297**] or
[**Telephone/Fax (1) 54298**]; [**Doctor Last Name 11923**] (BMT SW, knows pt well) pager [**Numeric Identifier 54299**]; needs
translator for any medical discussions
.
#. Dispo: on [**11-18**] family and patient decided that patient was
to be extubated to allow her an opportunity to communicate with
her family prior to withdrawal of the intra-aortic balloon pump.
Patient expired shortly after discontinuation of the
intra-aortic balloon pump from cardiac and respiratory failure.
Medications on Admission:
ativan PRN for nausea, pt denies any meds OTC or herbal
supplements
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiomyopathy.
Congestive heart failure.
Endocarditis (culture positive).
Abdominal pain.
Acute renal failure.
Portal vein thrombosis.
Thrombocytopenia.
Acalculous cholecystitis.
Acute myelogenous leukemia.
Anxiety.
Discharge Condition:
expired
Completed by:[**2169-4-26**]
ICD9 Codes: 4280, 5849, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4437
} | Medical Text: Admission Date: [**2188-4-7**] Discharge Date: [**2188-4-10**]
Date of Birth: [**2104-3-26**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Ultram / Vicodin
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known firstname 13842**] [**Known lastname **] is a 84 yo woman with history of CAD, Afib
(not on coumadin), HTN, DM2, spinal stenosis, diverticulosis and
diverticulitis who presented to an OSH from her nursing home
after having 2 bloody bowel movements on [**2188-4-5**]. Her
hematocrit on day of admission had fallen from mid 30s to 28.
She received IVF and 1 u pRBC. She underwent abdominal CT which
suggested sigmoid diverticulitis. Due to this finding GI did
not want to pursue endoscopy. She was started on cipro/flagyl.
She underwent red blood cell scan which was negative. She
continued to have bloody bowel movements over the next day and
had a hematocrit drop from 30.9 to 23.8. She received an
additional 2 u pRBC with an appropriate hematocrit response.
Since the this transfusion on the evening of [**2188-4-6**] her
hematocrit has remained stable at Per the family's request the
patient was transferred to [**Hospital1 18**] ICU for further monitoring and
management.
On arrival to the ICU she is drowsy and disoriented but easily
arousable. She is inattentive but denies pain, sob, chest pain,
or any other complaints.
Per family, she has does not have any history of abdominal
surgeries, liver disease, or recent GI illness. She did have a
single episode of hematemesis on [**2188-4-5**] when she first
experienced BRBPR. She reports only cramping abdominal
discomfort prior to bowel movements. Denied other abdominal
pain, nausea, fevers or chills. Family witnessed a bowel
movement earlier today that appeared black and tarry.
Past Medical History:
Dementia
CAD s/p CABG [**2178**]
Afib (not on coumadin)
HTN
DM2
Depression
Spinal Stenosis
Diverticulosis/Diverticulitis
Social History:
Patient lives at [**Location **] Immaculate Nursing Center. She has no
history of tobacco, etoh or drug use. She is ambulatory with a
walker. She has several family members who are involved in her
care.
Family History:
noncontributory
Physical Exam:
VS: T 98.9 HR 61 BP 132/61 RR 17 SpO2 98% 2 L NC
GEN: The patient is in no distress and appears comfortable
SKIN:No rashes, scattered echymoses on forarms
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted. EOMI, pupils small
reactive
CHEST: Lungs are clear anteriorly, rales, or rhonchi.
CARDIAC: RRR, 2/6 systolic murmur at RUSB
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis, 2+
distal pulses
NEUROLOGIC: Drowsy, easily arousable to verbal stimuli, oriented
to person, inattentive, moving all four extremities
Pertinent Results:
[**2188-4-5**] GI bleeding scan: Initial dynamic and 24-hour delayed
images do not show any significant focal areas of increased
uptake.
[**2188-4-5**] CT Abdomen/Pelvis w/o IV contrast: Uncomplicated sigmoid
diverticulitis.
Brief Hospital Course:
84 yo female with history of dementia, CAD, Afib (not on
coumadin), diverticulosis and diverticulitis who presents from
OSH with BRBPR and hematemesis. She was initially admitted to
the MICU and then transferred to the floor on hospital day 2.
Hospital course will be reviewed by problem.
GIB: Her GI bleed was likely lower in origin secondary to
diverticulosis given significant diverticulosis on CT scan. In
addition the patient has diverticulitis noted on imaging.
Initially she received 4 units of PRBCs (3 at the OSH and 1 at
[**Hospital1 18**]) to keep her hematocrit above 25%. HCT was then stable
and she was hemodynamically stable. She was continued on a PPI
twice daily for a history of possible hematemesis. GI was
consult (Dr. [**Last Name (STitle) 349**] and had thought the risk of
endoscopy/colonoscopy would outweigh the benefit given the
current diverticulitis. She and her family will follow-up with
her primary care physician to discuss whether a colonoscopy is
desired. GI recommended a colonoscopy only if the family
desires screening for and treatment of potential colon cancer.
They did not feel endoscopy was necessary. She will continue on
a PPI twice daily for one month and then transition to once
daily. At the time of discharge, her stools were maroon and
guaiac positive but per GI this was to be expected following her
GI bleed.
Diverticulitis: She was initially started on IV Cipro and
flagyl with the intention of a 14 day course. She was then
transitioned to a po course of levofloxacin and flagyl (renally
dosed).
Cough: Per the patient's daughter, Ms. [**Known lastname **] had a new cough.
She had a CXR concerning for LLL PNA versus atelectasis,
however, she had a clear lung exam and good oxygen saturations
on room air. PNA was felt to be unlikely and she was not
treated for these symptoms. Cipro was switched to levo for
better lung penetration in case there was an aspiration event.
Atrial Fibrillation: Patient was rate controlled on metoprolol
and amiodarone. These were continued while aspirin was held
given GI bleed. On discharge she was instructed to restart her
aspirin 81 mg in one week.
Type 2 diabetes: She was kept NPO while bleeding and started a
po diet on [**4-9**]. She was initially put on a sliding scale and
then on [**4-10**] put on her home dose oral hypoglycemics.
She was discharged to her nursing home on [**4-10**] in stable
condition.
Medications on Admission:
Aspirin 81 mg
amiodarone 100 mg daily
Lisinopril 40 mg daily
Metoprolol 75 mg po bid
Glyburide 2.5 mg daily
Prilosec 20 mg daily
Aricept 10 mg daily
Citalopram 30 mg daily
Mulitvitamin daily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. 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:*0*
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Restart in one week.
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for until [**2188-4-19**] days.
Disp:*5 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Start in one
month.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
Immaculate [**Hospital **] Nursing Home
Discharge Diagnosis:
Primary:
Diverticulitis
GI bleed
.
Secondary:
Dementia
CAD s/p CABG [**2178**]
Afib (not on coumadin)
HTN
DM2
Depression
Spinal Stenosis
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were transferred to [**Hospital1 69**]
Medical Intensive Care Unit for evaluation of your
diverticiulitis and GI bleed. You were given four units of
blood (including those at the original hospital) and your blood
levels remained stable after this. You were seen by
gastroenterology, who recommended a colonoscopy as an
out-patient if you desire screening and treating a possible
cancer. You were treated with antibiotics for your
diverticulitis and remained afebrile.
The following medication changes were made:
Levofloxacin 750 mg every other day was ADDED until [**2188-4-19**]
Flagyl 500 mg three times daily was ADDED until [**2188-4-19**]
Pantoprozole 40mg twice daily was ADDED for one month, then
switch to once daily.
RESTART aspirin 81 mg in one week
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week.
Please discuss whether you want a colonoscopy to screen for
cancer. This colonoscopy should not be done for at least one
month.
ICD9 Codes: 311, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4438
} | Medical Text: Admission Date: [**2102-5-8**] Discharge Date: [**2102-5-13**]
Date of Birth: [**2048-2-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
dyspnea, peripheral edema
Major Surgical or Invasive Procedure:
1. Right heart catheterization
History of Present Illness:
54 yo man currently undergoing evaluation for heart transplant
for severe cardiomyopathy previously treated with weekly
nesiritide infusions in [**Hospital 1902**] clinic admitted [**3-8**] with
progressive dyspnea, LE edema, and weight gain (home scale up to
315 lbs from 298) over the past two weeks. Three weeks prior to
admission, pt was admitted to OSH for diuresis with furosemide.
Patient states his LE edema improved but was not diminished to
the same degree as it was following his hospitalization here in
[**1-28**]. Since his discharge from the OSH two weeks ago, he has
had progressive exertional dyspnea and LE edema despite
compliance with his sodium and volume restriction. He phoned
the [**Hospital 1902**] clinic [**3-8**] and was referred for hospitalization for
tailored diuresis.
Also of note, on [**3-8**] he noted maxillary > frontal sinus pain
with nasal discharge (initially brown, now chartreuse per
patient) and cough productive of similarly colored sputum. No
f/c/s. Symptoms are persistent but improving. He has been
taking naproxen and OTC decongestants for relief.
He denies increasing orthopnea, chest pain, palpitations,
abdominal pain, n/v, diaphoresis, or dysuria.
Past Medical History:
1. Non-ischemic cardiomyopathy (LVEF 15-20% [**1-28**])
2. DM-II c/b neuropathy
3. hypertension
4. dyslipidemia
5. obesity
6. chronic renal failure (baseline Cr 1.6)
7. RLE cellulitis [**12-28**]
8. thyroid lymphoma s/p XRT [**2084**], now hypothyroid
Social History:
Pt is retired from owning a printing business. Works in wife's
daycare. Pt is married with three grown children. No EtOH. Quit
tobacco 20 yrs ago (smoked <1 pack per week).
Family History:
Non-contributory
Physical Exam:
Temp 98.7, BP 113/80, HR 69, RR 16, SpO2 98% RA
Gen: Very pleasant, comfortable, non-toxic
HEENT: Diminished but significant L > R maxillary sinus
tenderness, no frontal sinus tenderness
Neck: Soft, supple, no cervical adenopathy, 2+ carotid pulses,
minimal JVD (?7 cm, limited by body habitus), post-thyroidectomy
scar
CV: RRR, normal S1 and S2, no m/r/g
Pulm: CTA bilaterally
Abd: Soft, non-tender, non-distended, active bowel sounds
Back: No CVA or paraspinal tenderness
Ext: Trace BLE pitting edema, 2+ DP and 1+ PT pulses
bilaterally, right greater than left LE chronic venous stasis
changes, equal warmth bilaterally
Pertinent Results:
Labs on admission:
WBC-7.2 (N-80.4 L-10.6 M-6.0 E-2.8 B-0.3) Hct-48.1 MCV-83
Plt-268
PT-13.6 PTT-27.4 INR-1.2
Na-143 K-3.5 Cl-98 Bicarb-32 BUN-32 Cr-1.6 Glu-166
U/A negative
Labs on transfer:
WBC-7.6 Hct-42.9 MCV-85 Plt-240
Na-143 K-3.6 Cl-101 Bicarb-32 BUN-29 Cr-1.5 Glu-78 Ca-9.1 Mg-1.9
Phos-3.7
R Heart Cath ([**2102-3-9**]): C.I. 1.60 L/min/m2, PCWP 22, PA 47/25,
RV 47/5, RA mean 10
Metabolic Stress Test [**2-25**]: VO2 of 8
TTE [**1-28**]: Mild symmetric LVH, moderately dilated LV, severe
global LVHK, severely depressed LVEF (15-20%), moderately
dilated aortic root and arch, moderately dilated ascending
aorta, 1+ MR
CCath [**12-27**]: Clean coronary arteries, moderate diastolic
dysfunction, low cardiac index (1.6-1.8 L/min/m2).
Brief Hospital Course:
54 yo man with severe dilated cardiomyopathy admitted for
tailored diuresis, now nearly at his baseline clinical status.
1. Congestive Heart Failure: Patient with known, severe,
non-ischemic, dilated cardiomyopathy as per HPI. Precipitant
for deterioration in cardiac function on admission unclear,
although patient may simply have severe CHF refractory to
outpatient control. No symptoms to suggest cardiac ischemia.
Recent NSAID and probable viral sinusitis may have been
contributing factors. Since admission, right heart cath
demonstrated elevated right and left sided filling pressures and
a depressed cardiac index. Attempted tailored diuresis with
milrinone resulted in an increased cardiac index and decreased
PCWP but was complicated by acute renal failure due either to
peripheral vasodilatation and poor renal perfusion or
obstructive nephropathy (the patient's Foley catheter may have
been obstructed). Since the milrinone was stopped on [**5-10**], his
renal function has returned to baseline, and he has diuresed
well. His net fluid balance this admission is roughly three
liters negative. His PA catheter has been removed and he is
stable for transfer to the floor.
- Furosemide 80 mg twice daily, carvedilol 25 mg twice daily,
ASA 81 mg daily
- Spironolactone 25 mg once daily, lisinopril 20 mg once
daily, metolazone qFri
- Daily weights
- Continue fluid and sodium restriction
- No further NSAIDs
- Transplant evaluation unremarkable to date
2. Sinusitis: Most likely viral given course of symptoms
(gradually improving), although exquisiste maxillary sinus
tenderness suggests possible bacterial superinfection,
especially given colored nasal discharge. Symptoms persist but
are improving.
- Doxycycline 100 mg twice daily for three more days
- Continue saline and steroid nasal sprays (pt instructed re:
proper usage)
- Consider sinus CT if symptoms do not continue to improve
3. Acute Renal Failure: Creatinine now back at baseline.
- Lisinopril dose increased today
- Recheck BUN and creatinine in the morning
4. Diabetes: Adequacy of outpatient control not clear.
- Continue twice daily NPH, add RISS while in-house
- Restart outpatient glyburide
- Continue gabapentin for neuropathic pain
5. Hypothyroidism: Continue levothyroxine 250 mcg daily
6. Gout: Patient reports gouty attacks have been precipitated by
high-dose furosemide in the past. He reports that plans to
transition from colchicine to allopurinol have been thwarted by
recurrent hospitalizations. He has, however, been stable off
colchicine thus far.
- Continue to hold colchicine
- Plan outpatient transition to allopurinol
7. Proph: Low-sodium diet, OOB
8. F/E/N: Fluid and sodium restriction as above. Recheck AM
lytes.
9. Access: Peripheral IVs.
10. Code: Full.
11. Dispo: Possible discharge tomorrow.
Medications on Admission:
1. carvedilol 25 mg twice daily
2. spironolactone 25 mg twice daily
3. furosemide 80 mg twice daily
4. lisinopril 10 mg once daily
5. metolazone 2.5 mg every Friday
6. NPH 15 units twice daily
7. potassium chloride 40 mEq once daily
8. glyburide 10 mg daily
9. aspirin 81 mg once daily
10. levothyroxine
11. colchicine 0.6 mg twice daily
12. gabapentin 800 mg twice daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. non-ischemic dilated cardiomyopathy
2. systolic congestive heart failure
3. acute renal failure
4. sinusitis
5. diabetes mellitus type II
6. hypothyroidism
7. hypertension
8. obesity
9. chronic renal failure
Discharge Condition:
Pt appears to be at his dry weight, symptom-free with no lower
extremity edema.
Discharge Instructions:
1. Take all medications as prescribed.
2. Remember to weigh yourself daily and call Dr.[**Name (NI) 23312**] office
with any weight gain.
3. Continue to abide by a low-sodium (less than two grams daily)
diet.
4. Continue your fluid restriction at less than 1500 mL daily.
Followup Instructions:
1. Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3512**]) on Monday [**2102-5-15**] to arrange for
a follow-up appointment with her at her discretion.
2. Follow-up with your primary care physician as previously
arranged.`
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2104-1-1**]
ICD9 Codes: 5849, 4254, 4280, 2749, 4168, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4439
} | Medical Text: Admission Date: [**2154-5-5**] Discharge Date: [**2154-5-7**]
Date of Birth: [**2071-6-2**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Risperidone / Oxycodone /
Dilaudid / Codeine / Vicodin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R sided weakness and trouble speaking
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
82 yo RH woman with h/o Afib (not on coumadin [**1-7**] multiple
falls), HTN, PD, CAD, recent IVH [**1-7**] fall who presents after
being found down. She was speaking to her son-in-law this am
~9am who found her initially to be speaking normally (although
conversation was brief but able to ask about her daughter who is
out of the country) - incidentally she called him. However,
soon
after the call, he was answering a question and then noted no
response on the other end of the telephone. He called her name,
but heard no response. A friend had been planning to pick her
up
at 10 am, so he figured the phone was having technical
difficulties and that he would be contact[**Name (NI) **]/seen by the people
she was supposed to meet. He didn't hear anything and presumed
that things were ok. ~12:30, her daughter in law came by her
apt
to see how she was doing. When she knocked, she heard someone
(the pt) trying to say something but not really saying anything
clearly. She called 911 and the fire dept responded, broke open
the door and found the patient dressed (ready to go out per
children), unable to communicate - not making word salad, but
only word that was understandable was "no" with r sided
weakness.
As a result, she was brought to [**Hospital1 18**] ED where she was SBPs in
150. she could follow simple commands, but was not moving her
RUE. she also appeared to have trouble getting words out per ED
staff. She was then intubated for airway protection. CTH was
attained which revealed hypodensity involving LMCA territory
with
small amount of hemorrhage concerning for hemorrhagic conversion
of infarction and neurology service was contact[**Name (NI) **].
Incidentally, the patient's children describe her as having
gradual worsening of her language with worsening word finding
difficulties over the past year. After a recent admission for
IVH, she has also had a tendency to sit with her eyes close
(although awake) per their report.
Per family, patient with h/o TIA with dysarthria and L hand
"shaking" lasting minutes. they don't recall results of workup
from [**2140**].
ROS:
Gen: pt unable to relate. but per family, no recent illness, no
complaints of HA, no other previous weakness, vision changes,
sensory symptoms.
Past Medical History:
Atrial fibrillation-diagnosed [**12-11**] (on Coumadin)
Arthritis
CAD (inferolateral reversible defect per MIBI in [**2146**])
Zoster
Asthma
Arthroscopic surgery to knees (bilat)
Wrist [**Doctor First Name **]
TAH
CCY
Hypothyroidism
TIA in [**2140**] (self limited with no residual defecits)
Osteoporosis
Parkinson's disease
Hypertension
Hiatal hernia
Social History:
Lives alone in an apartment. Her daughters are involved. She
denies alcohol, tobacco and illicit drugs.
Family History:
No significant
Physical Exam:
VS: T 97.3 HR 62 BP 154/94 RR 18 Sat 100% RA
PE:
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS irregularly irregular
ABD soft, NTND, + BS
SKIN
NEUROLOGICAL
MS: intubated, sedated on propofol. when taken off, BPs into
200s
eyes closed, not following commands, no spont eye opening or eye
movements. spont movements of all extremities except RUE.
CN: surgical pupils bilaterally, + corneal reflexes Bilaterally,
no OCRs, no gag, no grimace noted. pt with ETT taped onto R NLF
Motor: tone: increased tone throughout. moving extremities
except for RUE spontaneously. With noxious to RUE, localizes
with left, but no movement noted on R. LLE moving greater than
RLE, but RLE is easily antigravity.
[**Last Name (un) **]: all extremities save for RUE withdraw to mild stim
Reflex: 2+ bilaterally, except for ankles 0. toe on L is up. toe
on R is mute.
Pertinent Results:
[**2154-5-5**] 03:11PM GLUCOSE-116* LACTATE-2.2* NA+-143 K+-3.5
CL--95* TCO2-31*
[**2154-5-5**] 02:55PM GLUCOSE-122* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18
[**2154-5-5**] 02:55PM CK(CPK)-106
[**2154-5-5**] 02:55PM CK-MB-7
[**2154-5-5**] 02:55PM cTropnT-0.01
[**2154-5-5**] 02:55PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2154-5-5**] 02:55PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2154-5-5**] 02:55PM WBC-8.3 RBC-3.89* HGB-12.5 HCT-37.7 MCV-97
MCH-32.2* MCHC-33.3 RDW-14.4
[**2154-5-5**] 02:55PM NEUTS-83.1* LYMPHS-11.1* MONOS-4.5 EOS-0.7
BASOS-0.6
[**2154-5-5**] 02:55PM PLT COUNT-235
[**2154-5-5**] 02:55PM PT-13.7* PTT-27.1 INR(PT)-1.2*
[**2154-5-5**] 04:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2154-5-5**] 04:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2154-5-5**] 11:21PM TYPE-ART PO2-494* PCO2-36 PH-7.56* TOTAL
CO2-33* BASE XS-10
[**5-5**] CT head: Large hypodense area concerning for acute ischemia
in distribution
of left MCA, with foci of blood products. MRI is recommended for
further
evaluation, and neurology consult. Findings were discussed with
Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 780**] at 4:10 p.m. on [**2154-5-5**] and posted on the ED dashboard.
2. Scattered area of low attenuation in the subcortical white
matter on the
right, likely consistent with chronic small vessel ischemic
changes.
3. No evidence of fracture.
[**5-5**] CT head after change in exam:
1. Massive hemorrhagic conversion of a left MCA territory
infarct with local
mass effect, including effacement of the left lateral ventricle
including near
complete effacement of the left lateral ventricle, as well as
significant
subfalcine and left uncal herniation. Some mild interval
dilatation of the
right lateral ventricle atrium should be monitored on followup
examinations.
Brief Hospital Course:
Mrs [**Known lastname **] was admitted to the ICU with large LMCA infarction. No
intervention was indicated as she was outside the window.
Overnight she had a change in her pupilary exam and stat repeat
head CT was ordered. She was found to have massive hemorrhagic
conversion of her stroke. She was not on any anti-platlet or
anticoagulants at the time. Full medical management was
maintainted until [**5-7**] when her daughter [**Name (NI) **] was able to arrive
home from [**Country 84997**]. On [**5-7**] after a family meeting with bother
daughters, son-in-law, [**Name (NI) 18198**], and other family members
care was withdrawn and she was made comfort measures only. She
passed away shortly after extubation.
Medications on Admission:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
QID (4 times a day).
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): in one week (starting [**2154-1-24**], dose should be
incresed to 750 mg [**Hospital1 **] foe one week, then (on [**2154-1-31**]), dose
should be increased to 1000 mg [**Hospital1 **], as long as pt.s mental
status remains clear. If there are questions about this,
contact pt.s primary care MD, Dr. [**Last Name (STitle) 2204**] at [**Telephone/Fax (1) 20792**].
Tablet(s)
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
Discharge Medications:
None, pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Massive hemorrhagic conversion of a left MCA territory infarct
with local mass effect, including effacement of the left lateral
ventricle including near complete effacement of the left lateral
ventricle, as well as significant subfalcine and left uncal
herniation
Atrial Fibrillation
Discharge Condition:
Expired
Discharge Instructions:
The patient was admitted with a large left MCA infarct with
large hemorrhagic conversion and subfalcine and left uncal
herniation. The patient was made CMO, and expired with her
family at the bedside.
Followup Instructions:
None
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2154-5-10**]
ICD9 Codes: 431, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4440
} | Medical Text: Admission Date: [**2123-6-11**] Discharge Date: [**2123-6-23**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Acute on chronic renal failure
Major Surgical or Invasive Procedure:
Intubation, Extubation
Placement of nephrostomy tube on left and a stent of right
ureter
Irrigation and debridement of right wrist
History of Present Illness:
79yoM with h/o OSA, CAD s/p MI and CVA, diastolic CHF admitted
to [**Hospital1 18**] [**Date range (1) 12728**] with sepsis secondary to Klebsiella
bacteremia, admitted again on [**6-11**] to Urology service from rehab
with acute renal failure, transferred to MICU [**6-12**] with MRSA
bacteremia, ARF, and respiratory failure.
.
Patient was admitted [**Date range (1) 12728**] with sepsis due to Klebsiella
bacteremia. Source of Klebsiella infection was not known, but
was thought to be from pneumonia seen as retrocardiac opacity on
CXR. Urinalysis was negative at that time. He was intubated
during that admission for airway protection and hypercarbic
respiratory failure. Although he has OSA, he is not a CO2
retainer. He was discharged to [**Hospital3 **] to complete at
14day course of levofloxacin, to which the Klebsiella (from
culture at [**Hospital 4199**] Hospital) was sensitive. During his initial
presentation he did develop ARF with creatinine up to 2.8 from
baseline of 1.7-1.9. Creat returned to baseline during the
hospitalization. It rose to 2.0 prior to discharge after ACE-I
was restarted.
.
He was transferred to [**Hospital1 18**] ED [**2123-6-11**] after two days of
intermittent right sided abdominal pain, decreased urine output,
anorexia, and temp spike to 101. According to the patient's
wife, he did not feel himself soon after admission to rehab,
refusing to eat, being lethargic and unwilling to participate in
rehab activity. In the ED patient found to have ARF with creat
7.3, [K+] 5.1. CT showed right UVJ stone, right perinephric
stranding, left ureteral stone, and hydronephrosis. He was
admitted to Urology service and underwent left percutaneous
nephrostomy tube placement. He was also found to have UTI and
was started empirically on Vanc/Levo/Ceftriaxone. Urine culture
and blood cultures (4/4 [**6-11**]) grew MRSA, and CTX/Levo were
discontinued [**2123-6-13**]. Despite nephrostomy tube placement,
patient continued to have ongoing oliguric renal failure, which
renal felt was due to persistant obstruction vs ATN. He was not
hemodialyzed.
.
On [**2123-6-14**] he underwent right ureteral stent placement,
retrograde pyelography, and removal of stones. He remained
intubated post-operatively.
On [**2123-6-17**]- Pt also complained of right wrist pain/swelling and
subsequently was found to have septic wrist. This was irrigated
and debrided on [**6-17**]. Cultures positive for MRSA.
On [**2123-6-19**], pt was extubated.
On [**2123-6-20**], pt transferred to CC-7A. Reported feeling weak.
Denied HA, dizziness, chest pain,palpatations, SOB, cough,
abdominal pain, constipation, diarrhea, edema.
Past Medical History:
CVA - [**2117**] with residual right-sided weakness
post-concussive syndrome
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI in 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-24**] EGD with gastritis, colonoscopy with
diverticulosis
Depression
s/p right shoulder surgery
s/p knee replacement
s/p bilateral nephrostomy tube placement
Social History:
He lives with his wife; daughter lives downstairs.
Tob: h/o cigarrette smoking, quit 22yrs ago
EtOH: denies
Family History:
h/o prostate cancer and hemorrhagic stroke
son d. MI at 50yrs
broth d. complications of TIIDM
Physical Exam:
VS T P BP RR O2 sat
Gen- Obese male, lethargic, nodding off during exam, NAD
HEENT- AT, NC, PERRLA, EOMI, sclera anicteric, MMM, oropharynx
clear
Neck- large neck, no JVD or LAD
Cor-RRR, no MGR
Lungs- coarse breath sounds-upper airways, posteriorly CTA B/L
Abd- obese, nontender, nondistended, + BS, no HSM or masses,
nephrostomy site-no erythema, induration or oozing from site
Extrem- right wrist wrapped in bandage-clean/dry/intact, no
edema of lower extremeties
neuro-CN grossly intact, sensation intact, strength diminished
on R side-both upper and lower [**3-24**].
Pertinent Results:
Imaging:
[**2123-6-19**] post-extub CXR: Endotracheal tube has been removed.
Feeding tube and left PICC line remain in place. Cardiac and
mediastinal contours are stable. Left lower lobe atelectasis is
slightly improved. Moderate left effusion is unchanged
[**2123-6-16**] echo: The left atrium is mildly dilated. The left
ventricular cavity size is normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal
(LVEF>55%). The right ventricle may be mildly dilated. Right
ventricular
systolic function is normal. 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. The
tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
[**2123-6-13**] CT Abd/pelvis
1. Status post left nephrostomy. New 1.2-cm oval-shaped focal
density, which may be related to recent nephrostomy. Persistent
left ureteral stone and right obstructing UVJ stone, measuring 3
mm with hydronephrosis and hydroureter. No obstructing right
renal stones.
2. Heterogeneous density of the kidneys, especially on the
right, with 2.6 cm high-dense focal lesion. As suggested on the
prior study, these lesions can be further evaluated by
ultrasound.
3. Persistent fat stranding along the ascending colon, unchanged
compared to the prior study.
4. Limited study without intravenous contrast [**Doctor Last Name 360**]. Ectatic
appearance of iliac bifurcation.
Micro:
[**2123-6-19**] CATHETER TIP-IV Source: left SC TLC.
WOUND CULTURE (Preliminary): No significant growth.
[**2123-6-17**] 5:00 pm SWAB Site: ARM RIGHT WRIST WOUND.
GRAM STAIN (Final [**2123-6-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2123-6-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
[**6-15**] and [**6-16**]- blood cultures x 2 negative
[**2123-6-15**]
GRAM STAIN (Final [**2123-6-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2123-6-17**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12729**] [**2123-6-16**] AT 12PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**6-11**] bld Cx positive for coag + staph
[**6-12**] urine Cx positive for coag + staph
[**6-12**] positive MRSA screen
Brief Hospital Course:
MICU course:
Pt was admitted to the MICU after he underwent R ureteral stent
placement, but became difficult to wean from the vent
post-operatively, and also was found to have MRSA bacteremia.
He also grew out MRSA from his urine as well, and also from his
R wrist. He was treated with vancomycin, dosed for level<15.
Plastic surgery was consulted for his R septic wrist, and he
went to the OR for washout of this joint. He had a TTE, which
was negative for vegetation. Surveillance cultures were
negative x 3 days. Pt continued to be in ARF, despite R
ureteral stent placement and L percutaneous nephrostomy. Renal
service was consulted, and pt was believed to have ARF secondary
to both recent obstructions as well as ATN. His diuretics were
held, and his Cr began to improve. He then progressed into the
post-obstructive diuresis phase, and renal service signed off.
His meds were renally dosed during this time. Pt was extubated
on [**2123-6-19**], and tolerated extubation well. Pt was restarted on
metoprolol and norvasc, but his ACEI and Lasix continued to be
held. He was continued on ASA and Plavix during his MICU stay.
He became hypertensive to 150's-160's during the end of his MICU
course, and his metoprolol was uptitrated. Pt was maintained
nutritionally by tube feeds while intubated, but began to have
thickened liquids after extubation. Pt had minor R leg pain
prior to leaving the ICU, but this pain resolved spontaneously.
RLE u/s was negative for DVT. Of note, pt repeatedly had his
NGT curled in his upper esophagus, despite repeated attempts at
replacement. This may suggest an abnormality in his upper
esophagus, which could be evaluated in the future.
.
.
1. Acute renal failure- The pt has a baseline creatinine of
1.7-1.9. On the last admission to the hospital on [**6-4**], pt had
creatinine rise to 2.8. This returned to 2.0 upon discharge to
rehab facility. On presentation for this hospitalization [**6-11**],
the pt was found to have a creatinine of 7.3 and K of 5.1. On CT
scan, pt found to have obstructing R UVJ stone and left ureteral
stone. He underwent left percutaneous nephrostomy and placement
of right stent. He was also found to have MRSA UTI and is being
treated with vancomycin. Despite nephrostomy tube placement and
stent, pt continued to have renal failure. This was thought to
be due to persistent obstruction and ATN. He was never dialyzed.
His creatinine has been trending down daily and is currently 3.8
and improving. He will need to follow-up with urology, Dr. [**Last Name (STitle) 4229**]
in [**12-21**] weeks.
.
2. MRSA [**Name (NI) 12007**] Pt is currently on day 9 of vancomycin.
.
3. MRSA bacteremia- positive blood cultures on [**6-11**].
Surveillance cultures on [**6-15**] and [**6-16**] were negative and [**6-17**]
blood cultures are negative to date. Given his septic wrist, he
needs to continue vancomycin for a total 4 week course(start
date [**2123-6-14**]) with daily vanc troughs checked given his ARF.
.
4. Septic wrist- S/P surgical irrigation and debridement. Wound
not erythematous or indurated. Cultured positive for MRSA. Last
wound Cx on [**6-17**] showed coag neg staph. [**6-19**] Wound catheter tip
negative. Pt needs to have 4 week course of vancomycin, start
date [**2123-6-14**]. Daily vanc troughs need to be checked with dosing
for levels<15.
.
5. Respiratory failure- pt intubated during surgery and could
not be extubated until [**2123-6-19**]. Tolerated extubation well.
Maintained on his home O2 dose of 2L continuous. )
.
6. [**Name (NI) 12730**] Pt usually wears CPAP at night, but was not very good
about using it at home. After intubation, he had CPAP 13 mm Hg
QHS.
.
7. CAD S/P MI 3 years ago and CVA in [**2117**] with residual R sided
weakness. No active issues currently. We continued ASA, Plavix,
Metoprolol, statin.
.
8. Diastolic CHF- Echo shows EF 55%. Pt has resolving left
pleural effusion. No JVD, crackles or LE edema on exam. CXR
showed mod left effusion is unchanged from previous studies
today. We did not need to give lasix as patient was in diuresis
phase of ATN. We continued betablocker and held aceI for ARF.
.
9. [**Name (NI) 3674**] Pt has history of iron deficiency anemia. Stools were
guaic negative. Crit stable throughout hospitalization, although
his Hct on discharge was at 24.6. He was given one unit of PRBC
for goal Hct>25, and needs to have a post-transfusion Hct drawn
tonight.
Medications on Admission:
Meds on Admission:
Levofloxacin 250mg po daily
Plavix 75mg daily
ASA 325mg daily
Fluoxetine 20mg daily
Zestril 5mg daily
Iron sulfate 325mg daily
Protonix 40mg daily
Multivitamin
Lopressor 50mg TID
Norvasc 5mg daily
.
Meds on Transfer:
Lasix 80mg iv BID
Propofol gtt
Metoprolol 50mg TID
Famotidine 20mg iv daily
Plavix 75mg daily
ASA 325mg daily
Fluoxetine 20mg daily
Fentanyl gtt
Heparin SC
Colace 100mg [**Hospital1 **]
Humalog insulin sliding scale
Haldol 3-4mg iv prn
Trazodone 25mg prn HS
Calcium gluconate prn
Albuterol prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Ten (10)
ML PO Q8H (every 8 hours).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Insulin
Continue insulin as detailed in the sliding scale sheet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary - MRSA bacteremia, MRSA septic wrist, MRSA UTI, ARF
Secondary - CAD, CHF, Iron deficiency anemia, h/o CVA, h/o OSA
Discharge Condition:
Stable, afebrile and improving Cr
Discharge Instructions:
-continue all medications as prescribed
-please follow-up with appointments as listed below
-continue Vancomycin for a total of six weeks (start date [**6-14**])
-daily vancomycin troughs need to be checked, beginning tomorrow
-you need to have a post-transfusion hematocrit checked tonight,
as you received blood today
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks for follow-up.
Completed by:[**2123-6-29**]
ICD9 Codes: 5849, 5990, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4441
} | Medical Text: Admission Date: [**2182-4-23**] Discharge Date: [**2182-5-1**]
Date of Birth: [**2123-10-15**] Sex: F
Service: NEUROLOGY
Allergies:
Fosphenytoin / Codeine / Morphine
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Witnessed seizure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 58-year-old right-handed woman with
metastatic breast cancer to the brain and ribs currently on
HK1-272 04-266 trial, now with chief complaint of witnessed,
grand mal seizure. She initially presented to [**Hospital3 3765**]
earlier today after generalized seizure witnessed by her
husband. [**Name (NI) **] is a very poor historian, but reports going to
her usual, psychotherapy appointment this a.m., in her usual
state of health. Afterwards, she walked out of the hospital with
her husband and then her story becomes a bit unclear. By report,
her husband witnessed a seizure lasting 2-3 minutes, involving
her arms and legs. She was observed to be snoring loudly after
seizure. Patient reports waking up in the ambulance on her way
to [**Hospital **] Hosp. At [**Hospital1 **], patient given fosphenytoin with
subsequent allergic reaction halfway through infusion with
pruritis, urticaria, erythema to abdomen. Infusion stopped and
she was treated with Benadryl 50 mg x 1, prednisone 40 mg x 1,
ativan 1 mg. Labs at [**Hospital1 **] with WBC 5.8, Hct 33.6 (MCV 83.6),
Plts 278, and CK 215. In our emergency room, her vital signs
were stable. She did not have further seizure activity, and she
was given 1,000 mg [**Hospital1 13401**] x 1 and admitted to OMED service. Head
CT was negative for acute process.
Past Medical History:
Oncology History: Somewhat unclear as patient longtime patient
of [**Hospital1 18**] and no recent synopsis of treatments:
-patient with breast cancer with stable mets to brain, ribs
-initially diagnosed with right breast cancer in [**2162**]. Biopsy at
that time revealed an infiltrating ductal carcinoma and the
patient underwent a mastectomy (tumor size was 4.5 cm, ER
positive, and Her2neu positive).
-approximately 14 months after mastectomy, underwent six cycles
of CMF therapy.
-[**2174**]: left hip met
-initiated care w/ Dr. [**Last Name (STitle) **] in [**2175**]; XRT and herceptin
-Navelbine and Herceptin
-Herceptin and carboplatin [**1-27**]
-now with brain and rib mets
-has been on multiple protocols
-currently on HK1-272 04-266 trial with several recent dose
reductions, Zometa last received on [**2182-4-16**]
-seen in ED on [**2182-3-21**] with rib pain, ruled out for PE, thought
to be due to known metastases.
OTHER PMH:
Asthma and elevated cholesterol.
Social History:
She lives w/ her husband, and she has 4 grown children. She is
a lifetime non- smoker and rare alcohol use.
Family History:
Non-contributory.
Physical Exam:
Vital Signs: Temperature 98.1 F, Blood Pressure 128/80, Pulse
117, Respiration 20, Oxygen Saturation 97% in Room Air.
General: Restless, moving all extremities all about,
alert/oriented, scattered; She is inattentive, and keep needing
to re-focus her for history
HEENT: MM dry, OP clear but dry; EOMI
NECK: supple, no lymphadenopathy, no rigidity
BREAST: mastectomy on right; port a cath c/d/i
CHEST: CTA; pruritic-uriticarial rash on anterior chest; patient
scratching actively
CV: RRR, no m/r/g; patient kept talking through exam even when I
asked her to be quiet for auscultation
ABD: soft non tender,nabs, no masses
EXTRM: swaying them around, decreased tone but normal strength
NEURO: alert and oriented x 3 but a few seconds later she said "
i am going to be transferred to [**Hospital3 **]." Appropriate but
needs constant re-focusing for questions. Scattered. Normal
speech. Moving all extremities about with ease. Spelled WORLD
foreward but not backward. Serial sevens with ease. Cerebellar
examination intact. did not ambulate patient.
Pertinent Results:
[**2182-4-23**] 06:00PM GLUCOSE-101 UREA N-12 CREAT-0.6 SODIUM-142
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
[**2182-4-23**] 06:00PM NEUTS-80.5* BANDS-0 LYMPHS-14.1* MONOS-2.9
EOS-2.5 BASOS-0.1
[**2182-4-23**] 06:00PM PT-12.1 PTT-21.6* INR(PT)-1.0
MRI Head [**2182-4-24**]:
FINDINGS: All of the sequences with the exception of the axial
FLAIR sequence are so severely limited by patient motion as to
be practically diagnostically useless. On the FLAIR sequence,
the extensive white matter edema in the periventricular regions
and the left temporal lobe are identified and are similar to the
previous examination. On the postcontrast sequence in today's
examination, the previously noted temporal lobe enhancing
lesions can be discerned. It cannot be compared adequately.
IMPRESSION: Markedly limited study due to patient motion.
Persistent white matter abnormal signal and enhancing focus in
the left temporal lobe.
MRI Head [**2182-4-26**]:
FINDINGS: Again, two small enhancing lesions are seen in the
left frontal cortical and subcortical region with mild
surrounding edema. Additionally, there is an approximately 15 mm
enhancing lesion seen in the left temporal lobe with a small
adjacent enhancing nodule. This lesion on axial images appears
slightly larger compared to the prior study. However, compared
on the sagittal and coronal images it remains unchanged.
Therefore, the differences on the axial images could be due to
slice selection. An additional small focus of enhancement is
seen adjacent to the occipital [**Doctor Last Name 534**] of the right lateral
ventricle. Diffuse periventricular and subcortical
hyperintensities are seen on the FLAIR and T2-weighted images
which could be related to small vessel disease and/or radiation
therapy. There is no mass effect or midline shift seen. There is
moderate ventriculomegaly which could be related to atrophy.
There are no other definite areas of abnormal parenchymal or
meningeal enhancement seen.
IMPRESSION: Overall, no significant interval change compared to
the previous MRI of [**2182-3-27**]. The left frontal and temporal
enhancing lesions are again seen with surrounding edema. A small
focus of enhancement is again seen adjacent to the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. Diffuse hyperintensities in
the white matter are again noted which could be related to small
vessel disease or radiation therapy.
EEG [**2182-4-25**]:
IMPRESSION: Normal portable EEG. There were no areas of
persistant focal slowing, no epileptiform feature. Tachycardia
was noted.
Brief Hospital Course:
This is a 58-year-old right-handed woman with metastatic breast
cancer to [**Last Name (LF) 500**], [**First Name3 (LF) **], here with new seizures, presumably from
disease progression. She was transferred to [**Hospital1 18**] for further
care given that her oncology care is here. She was intially
confused on [**2182-4-23**] overnight and was less so during [**2182-4-24**].
She continued to recieve Benadryl prn and in addition received
ranitidine, Zyrtec, and Ativan. On the evening of [**2182-4-24**], she
became increasingly confused and agitated requiring restraints
and a sitter and she was then no longer able to be managed on
the floor. She denied dysuria, cough, subj fever, pain. She was
noted to have some phlebitis on her left arm at the site of a
prior IV and her husband noted an increase in her urinary
urgency. She had no chest pain, shortness of breath, N/V/D. Her
agitation was possibly due to Benadryl given that she had a
similar reaction in the past to phenobarbitol. Most likely
etiology was polypharmacy - she has had steroids, multiple
anticholinergics (Benadryl, ranitidine, Zyrtec), and Ativan.
Also on ddx was non-convulsive status, infection (? UTI, ?
cellulitis at old IV site), primary effect of metastases. Her
Zyrtec and Benadryl were discontinued. She was monitored in the
ICU over the next 48 hrs and was transferred back to the floor
after her mental status had drastically improved with the d/c of
anticholinergics.
(1) Seizure/Mental Status Changes: Her grand mal seizure was
intially felt to be most likely from progression of disease.
She had an allergic reaction to fosphenytoin at the outside
hospital, so she was loaded with [**Date Range 13401**] on admission here. Her
electrolytes were within normal limits. She was afebriile. She
had no recent alcohol use or evidence of withdrawal from her
benzodiazepines. Head CT was negative for acute change. As per
above, she was very disoriented on admission and was transferred
to the ICU. She recovered from this event with lucid periods,
but was sundowning while in the ICU. The ddx for these MS
changes was long. The most likely was felt to be polypharmacy -
she has had steroids, multiple anticholinergics (Benadryl,
ranitidine, Zyrtec), and ativan. Also on ddx were non-convulsive
status, infection (? UTI, ? cellulitis at old IV site), primary
effect of mets. MRI of brain on admission was poor due to
patient movement but white matter edema in periventricular and
left temporal lobe regions seemed similar to one month ago. EEG
was negative for epileptiform features. LP was negative for any
cells and culture was negative. Repeat MRI [**2182-4-26**] showed left
frontal cortical and subcortical enhancing lesions with mild
surrounding edema unchanged from prior, 15 mm lesions left
temporal lobe unchanged, and lesion adjacent to occipital [**Doctor Last Name 534**]
of right ventricle unchanged. Following transfer back to the
floor from the ICU, she was continued on her [**Doctor Last Name 13401**]. On the
first 2 nights back on the floor she became very agitated,
requiring IV ativan. She was noted by nursing to have multiple
attempts to get out of bed when she was instructed not to. She
seemed very sleepy, barely able to sit upright. It was felt
these symptoms could be a side effect of [**Last Name (LF) 13401**], [**First Name3 (LF) **] her [**First Name3 (LF) 13401**]
was weaned to 250 mg po bid from 500 mg po bid and she was
started on lamictal 25 mg po bid. The following day, she was
much more alert and less agitated. She continued on Lamictal
and [**First Name3 (LF) 13401**], with the intention of discontinuing [**First Name3 (LF) 13401**] in [**5-30**]
weeks after the patient's Lamictal levels become therapeutic.
Her Lamictal is to be increased to 50 mg po bid on [**2182-5-11**].
She resumed her HKI-272 protocol drug on [**2182-4-29**].
(2) Metastatic Breast Cancer: The pt is currently on protocol
drug HKI-272. She has stable brain mets per MRI and a long
history of breast cancer, since [**2163**].
(3) Allergic Reaction: Given her allergic reaction to Dilantin
at OSH, she was started on Bendaryl, ranitidine and Zyrtec for
her hives. These medications were discontinued after she was
found to have an altered mental status.
(4) UTI: The patient was treated with a 7 day of Keflex.
(5) ? cellulitis: Patient had a very subtle area of likely
phelbitis over L wrist at site of old IV and restraints. She has
had cellulitis in past. She was treated with a 7 day course of
Keflex.
(6) Asthma: Continued outpatient advair/albuterol/flovent prn.
(7) Tachycardia: She had sinus tachycardia likely due to
dehydration and agitation. Her initial TSH level was elevated,
but on repeat her TSH and free T4 were within normal limits.
She states she has always had a fast heart rate.
(8) Agitation/Restlessness: This was likely initially secondary
to her altered mental status and then [**Year (4 digits) 13401**] side effect, as per
above. This was resolved by the time of discharge.
(9) Hyperlipidemia: Continued Lipitor per outpatient regimen.
Medications on Admission:
Zometa (last given [**4-16**]); oxybutynin qhs (she doesn't know dose)
Aleve two pills twice daily, Zyrtec, Nexium, Flonase, Advair,
vitamin B1, oxybutynin, 1 mg of warfarin for Port-A-Cath
patency, Singulair, magnesium and glucosamine chondroitin.
Although she has used Lomotil regularly in the past she is using
it only on a p.r.n. basis now as her stools have essentially
normalized.
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
13. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.
Release 12HR Sig: Five (5) ML PO Q12H (every 12 hours) as
needed.
14. HKI Sig: One [**Age over 90 881**]y (160) mg DAILY (Daily): HKI
272.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
Disp:*30 Tablet(s)* Refills:*1*
16. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal twice a
day as needed for itching: around port site.
Disp:*1 tube* Refills:*0*
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Program
Discharge Diagnosis:
Grand mal seizure.
Confusion/delerium related to polypharmacy.
Discharge Condition:
Stable, alert and oriented.
Discharge Instructions:
Please take all medications as prescribed. Please follow up with
Dr. [**Last Name (STitle) 724**]. Return to the ER if you experience a recurrent
seizure or change in mental status (ie confusion). Do not take
benadryl.
Followup Instructions:
1 Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2182-5-13**]
8:00
2. Please call Dr. [**Last Name (STitle) 724**] to schedule follow up for prior to [**5-11**].
He will discuss adjustment of your lamictal dose. Please call
Dr.[**Name (NI) 6767**] office tomorrow. [**Telephone/Fax (1) 1844**]
ICD9 Codes: 5990, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4442
} | Medical Text: Admission Date: [**2180-10-27**] Discharge Date: [**2180-11-2**]
Date of Birth: [**2122-7-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
nausea/vomiting, thrombocytopenia
Major Surgical or Invasive Procedure:
L burr holes for evacuation of L SDH
History of Present Illness:
58 y/o female with metastatic breast cancer was seen by heme/onc
for thrombocytopenia, plt count 8000. Patient presented with n/v
and a head CT was done which showed L chronic SDH. Neurosurgery
was then conulted for further neurosurgical workup.
Past Medical History:
# CHF: seen every 6 months by Dr.[**First Name (STitle) 2031**] at [**Hospital **].
# Breast Ca: on [**9-14**] started faslodex (Estrogen Receptor
Antagonist) monthly
# Osteoporosis
# ? GERD/Esophageal Spasms
# Scoliosis
Social History:
The patient lives at home with her husband who work from home.
Family History:
Non-contributory
Physical Exam:
BP:134 /79 HR:105 R18 O2Sats: 95% 2L
Gen: WD/WN, comfortable, NAD, lethargic, has difficulty keeping
eyes open
HEENT: Pupils: [**4-13**] bilarerally EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, opens eyes to physical stimuli and
needs prodding
Orientation: Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
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. islated muscle group exam limited secondary to
patient's
mental status, but subjectively 4 to 4+ strength on the right,
right pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Discharge Exam: Patient has expired
Pertinent Results:
CT HEAD W/O CONTRAST [**2180-10-27**]
1. Small acute bifrontal subfalcine subdural hematoma. Large
subacute left
frontoparietal subdural collection, but new since [**2180-10-4**].
2. Mass effect including 11 mm rightward shift of normally
midline structures. No evidence of significant transtentorial
herniation.
CHEST (PA & LAT) [**2180-10-27**]
No acute cardiopulmonary findings
CT HEAD W/O CONTRAST [**2180-10-29**]
1. Post-surgical changes, with pneumocephalus overlying the left
cerebral
convexity.
2. Residual left subdural hematoma, smaller in size from prior
study.
3. Persistent, but slightly improved, rightward shift of
normally midline
structures.
4. Stable acute subdural hemorrhage layering along the falx.
CT HEAD W/O CONTRAST [**2180-10-30**]
1. Interval slight increase in size of the left subacute
subdural hematoma.
2. No interval change in size or appearance of the subdural
hemorrhage along the falx.
3. Stable shift of normally midline structures since prior
examination.
4. No evidence of a new hemorrhage or mass effect.
CHEST (PORTABLE AP) [**2180-10-31**]
As compared to the previous radiograph, there is no relevant
change. Severe dextroscoliosis, substantial cardiomegaly without
evidence of overhydration. No safe evidence of larger pleural
effusions. No focal
parenchymal opacities suggesting pneumonia.
Brief Hospital Course:
Patient was admitted for a chronic L SDH with 8mm midline shift
to the SICU for Q1H neuro checks. She presented to the
hematology clinic for transfusion of platelets clinic for a very
low count of 8000 and was then transferred to [**Hospital1 18**] after an
episode of n/v. Her exam was difficult to obtain due to her
lethargy and a head CT was ordered for AMS and lethargy. Upon
examiniation, she was oriented x 3 and spontaneous with all
extremities, but her RUE was significantly weaker, [**3-16**]. On
[**10-28**], she was taken to the OR in the morning for L burr holes
to evacuated the SDH. Post operatively the patient was much more
alert and oriented, moving all extremities spontaneously and [**4-16**]
in the RUE. Head CT showed some pneumocephalus, but was overall
stable. She was observed in the ICU for tachycardia in the 100s.
She became more lethargic over the next day and repeat head CT
was stable in midline shift. Patient then had a very low
platelet count to [**Numeric Identifier 6085**] and was transfused to a goal of [**Numeric Identifier **].
Neuro and heme/onc consults were obtained. Dilantin level in the
AM was 22 where all antiepliptics were held that day. She will
recieve an EEG in the afternoon to rule out subclinical seizures
as a cause of her increase lethargy. Patient was seen by
heme/onc in the afternoon and discussed poor prognosis with
husband. Dr. [**First Name (STitle) **], the patient's primary oncologist, also spoke
to the patient and husband regarding poor prognosis and code
status. Patient was made DNR/DNI, considering hospice care and
pallative care will see patient to discuss these needs further.
On [**11-2**], husband has decided to make patient [**Name (NI) 3225**]. At 11:15 am,
patient passed away in the SICU with husband at bedside.
Medications on Admission:
CAPECITABINE [XELODA] - 500 mg Tablet - Two Tablet(s) by mouth
Twice daily x fourteen days then off seven days, then repeat.
EFFEXOR XR - 75MG Capsule
FULVESTRANT [FASLODEX] - (Prescribed by Other Provider) -
Dosage
uncertain
LETROZOLE [FEMARA] - 2.5 mg Tablet - 1 Tablet(s) by mouth once a
day
LORAZEPAM - 0.5 mg Tablet - [**1-14**] Tablet(s) by mouth Before bed as
needed for insomnia
ONDANSETRON HCL - 8 mg Tablet - One Tablet(s) by mouth every
eight hours as needed for nausea
OXYCODONE - 10 mg Tablet Sustained Release 12 hr - One Tablet(s)
by mouth every 12 hours as needed for pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - one Tablet(s) by mouth
every 4-6 hours as needed for nausea
TRIMETHOPRIM-SULFAMETHOXAZOLE - (Prescribed by Other Provider)
-
800 mg-160 mg Tablet - 1 Tablet(s) by mouth
Monday-Wednesday-Friday
Discharge Disposition:
Expired
Discharge Diagnosis:
L SDH
Metastatic breast CA
Thrombocytopenia
DIC
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2180-11-15**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4443
} | Medical Text: Admission Date: [**2144-3-23**] Discharge Date: [**2144-3-29**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation
L subclavian central line
Swan-Ganz catheter
History of Present Illness:
This is a 47 year old man with a history of HTN, DM, possible
NSTEMI but negative cardiac cath in [**11-14**], who presents with 2
days of increasing dyspnea. He felt well until about 2 days ago
when he noticed he was feeling more short of breath,
particularly when walking around his house. That night he was
unable to lie down to sleep, and was awake the whole night. He
normally sleeps on 1 pillow. He also noticed that his feet were
more swollen than usual. He has never had symptoms like this
before at any time. He does not know any of his medications, but
he says he has been taking them with the exception of labetalol
(which he missed "a few days" and lasix missed "1 day" - he did
not take any meds this morning at all). He has been taking his
insulin.
.
He otherwise denies F/C/NS, cough, CP, abd pain, N/V/diarrhea,
constipation, dysuria.
.
In the ED, VS were 99.7, 115, 213/119, 16, 96% (not clear on how
much O2). Eventually, he was recorded as satting mid-90s on 5L
nc. He was briefly tried on BiPAP, but did not tolerate it. He
apparently did not need it, and was put back on nc O2. He was
given aspirin and started on a nitro gtt. He was given lasix
80mg IV to which he put out 1200cc urine. Since his BP was not
yet adequately controlled, he was also given hydralazine 20mg
IV. SBP ranged 150-200 in the ED.
Past Medical History:
# HTN
# Insulin dependent DM
- has had multiple admissions for DKA in setting EtOH use
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
(last use many weeks ago)
# h/o NSTEMI: possible NSTEMI during admission in [**11-14**], but
cath later showed clean coronaries
Social History:
Lives w/ a friend, no children. Used to work part time as a
tire-changer, but currently out of work. Denies tobacco use.
Denies recent EtOH or cocaine use (per report daily EtOH use in
past, last use 6 months ago).
Family History:
Mother had diabetes, niece has diabetes. Denies FH of coronary
artery disease, hypertension, cancer, liver disease, or renal
disease.
Physical Exam:
VS: 98.9, 117, 185/97, 23, 98% on 2L nc
Gen: Appears comfortable, lying in bed at ~30 degree angle, no
accessory muscle use.
HEENT: L eye with conjunctival injection, R pupil reactive
(unable to assess L pupil as pt not able to keep eye open long
enough), MMM, OP clear
Neck: JVP 9-10cm
Lungs: Slight bibasilar crackles, otherwise clear
Heart: RRR, no m/r/g
Abd: +BS, soft, NT/ND
Extrem: 2+ edema b/l to knees
Pertinent Results:
Admission Labs
[**2144-3-23**] 08:18PM CK(CPK)-147
[**2144-3-23**] 08:18PM CK-MB-5 cTropnT-0.15*
[**2144-3-23**] 11:21AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2144-3-23**] 11:21AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2144-3-23**] 11:21AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2144-3-23**] 10:55AM GLUCOSE-175* UREA N-33* CREAT-2.8* SODIUM-140
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-22 ANION GAP-13
[**2144-3-23**] 10:55AM estGFR-Using this
[**2144-3-23**] 10:55AM CK(CPK)-232*
[**2144-3-23**] 10:55AM CK-MB-8 cTropnT-0.16* proBNP-9158*
[**2144-3-23**] 10:55AM WBC-5.7 RBC-2.98* HGB-8.7* HCT-27.7* MCV-93
MCH-29.3 MCHC-31.5 RDW-16.8*
[**2144-3-23**] 10:55AM NEUTS-63.2 LYMPHS-27.2 MONOS-6.3 EOS-2.1
BASOS-1.1
[**2144-3-23**] 10:55AM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+
[**2144-3-23**] 10:55AM PLT COUNT-288
[**2144-3-23**] 10:55AM PT-11.4 PTT-26.2 INR(PT)-1.0
.
[**3-23**] CXR: 1. New perihilar haziness likely due to pulmonary
edema given clinical suspicion for CHF. Differential diagnosis
includes viral and PCP pneumonia as well as lung disease due to
sarcoid.
2. Longstanding symmetrical bilateral hilar and mediastinal
lymphadenopathy highly suggestive of sarcoidosis.
.
[**3-24**] TTE: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 11-15mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
focal hypokinesis of the basal inferior wall and entire
inferolateral wall. There is normal systolic function of the
remaining segments. 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 leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small (0.5cm) pericardial effusion.
Compared with the prior study (images reviewed) of [**2143-11-19**],
the findings are similar.
.
[**3-26**] CT Chest: 1. Large bilateral consolidative changes within
the posterior lungs. Aspiration and/or pneumonia are considered.
2. Large bilateral pleural effusions.
3. At least small amount of ascites, partially imaged.
4. Mediastinal lymphadenopathy.
5. Multiple lung nodules.
6. Multiple tubes and lines as described.
.
[**3-26**] CT head:
Profound diffuse cerebral edema, with near complete effacement
of the fourth ventricle, supracellar and basal cisterns,
indicative of downward transtentorial herniation.
.
[**3-26**] TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is low
normal (LVEF 50%) secondary to hypokinesis of the inferior and
posterior walls. There is no ventricular septal defect. The
right ventricular cavity is dilated. Right ventricular systolic
function is borderline normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2144-3-24**], no major change is evident.
.
[**3-27**] EEG:
This EEG demonstrated a severe diffuse encephalopathy with no
clear cerebral electrical activity. No clear EKG, pulse, and
movement artifacts were noted throughout the recording as
described above.
Brief Hospital Course:
This is a 47 year old man with DM, HTN, sarcoid, CKD, clean
coronaries on cath in [**11-14**], who p/w dyspnea consistent with CHF
exacerbation.
.
He initially responded well to lasix and improved rapidly from
his apparent CHF exacerbation. This CHF exacerbation had
occurred in the setting of severe hypertension, which was
initially controlled with ntg gtt. He was given his usual PO
medications and ntg gtt was titrated off. BP was decreased from
210/110 -> 160s/70s over the course of the night. Patient was
comfortable on minimal O2 by morning. TTE showed EF 40-50%, no
significant change from prior. BNP was elevated at 9000. EKG
was unchanged from baseline, and the patient ruled out for MI.
.
Ophthalmology was consulted due to concern for acute angle
glaucoma. They recommended continued treatment with eye drops.
The patient's symptoms were beginning to improve.
.
Overnight on [**3-24**] patient had a witnessed aspiration event,
resulting on hypoxia, tachypnea, and ultimately patient tired
and required intubation. It is unclear what precipitated this
aspiration event. Antibiotics were initially held due to no
fever or WBC, likelihood of aspiration pneumonitis rather than
pneumonia. Following intubation, chest CT on [**3-26**] revealed
large bilateral pneumonias.
.
On the morning of [**2144-3-26**], the patient was noted to be less
responsive. He suddenly became profoundly hypotensive and
ultimately had a PEA arrest. He received epinephrine and
atropine (as well as bicarb, CaCl, etc) and regained a pulse.
After the arrest he was initially dependent on 4 pressors, some
of which were gradually weaned off over hours. Repeat TTE was
initially read as unchanged, but was later noted to have RV
dilatation. There was concern for RV infarction vs. PE. A
Swan-Ganz catheter was floated which showed elevated PA
pressures 59/30s and wedge 30. When the patient was stable
enough, he went for a head CT which showed profound diffuse
cerebral edema, with near complete effacement of the fourth
ventricle, supracellar and basal cisterns, indicative of
transtentorial herniation. The family (specifically sister [**Name (NI) 2270**]
and other family members) were updated on the patient's grave
prognosis and possibility of brain death. Code status was
changed to DNR/DNI. Neurology was consulted and patient felt to
have no chance of meaningful neurologic recovery, clinical
evidence of brain death. EEG showed severe encephalopathy. At
this point it came to light that the patient's estranged wife
(separated x14 years) had legal medical decision making rights.
No further aggressive treatment was indicated at this time.
.
Ultimately, the patient had another PEA arrest in the early
morning of [**2144-3-29**] and expired. His family (including wife and
sister [**Doctor Last Name 2270**] and his PCP were notified. The wife consented to
post-mortem examination.
Medications on Admission:
(per last d/c summary - patient does not know meds):
-Aspirin 325 mg DAILY
-Atorvastatin 80 mg DAILY
-Nifedipine 90 mg DAILY
-Labetalol 600 mg PO TID
-Tobramycin-Dexamethasone 0.3-0.1 % Drops OS QID
-Latanoprost 0.005 % Drops OU HS
-Pantoprazole 40 mg Q12H ??qd
-Scopolamine HBr 0.25 % Drops OS [**Hospital1 **]
-Dorzolamide-Timolol 2-0.5 % Drops OS [**Hospital1 **]
-Apraclonidine 0.5 % Drops OS TID ??
-Furosemide 40 mg PO DAILY ??
-Insulin Lisp & Lisp Prot (75-25) 25 units QAM and 25 units QPM
(patient was last d/c'd on 30U [**Hospital1 **], but has been taking only 25
[**Hospital1 **])
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
CHF exacerbation
respiratory failure, secondary to aspiration pneumonia
profound hypotension, leading to PEA arrest
cerebral edema and transtentorial herniation, leading to cardiac
arrest and death
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5070, 5849, 4275, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4444
} | Medical Text: Admission Date: [**2183-2-17**] Discharge Date: [**2183-2-20**]
Service: NEUROLOGY
Allergies:
Penicillins / Codeine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
L sided weakness - transfer from OSH after IV tPA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed woman with a PMH of HTN who
presented to an OSH with L sided weakness and slurred speech
around 10 this morning. This history is obtained from her OSH
records as the pt is not able to provide details of the event.
Per report she was in her USOH this morning when she had abrupt
onset L sided "hemiplegia and R gaze preference" around 10am.
She was taken to an OSH where she had an NIHSS of 13. A head CT
was done which was negative for bleeding (review, shows no
hypodensities or bleeding, mild diffuse atrophy). Her BP was
160/70 and her HR was in the 70's in SR. She also had screening
labs including a WBC and chemistry which were normal and her INR
was 1.0. Her troponin was 0.107 however her ECG showed no
changes. She was then given tPA at 12:20 (5.8mg bolus followed
by 53mg infusion). She was then transferred here for further
care.
ROS: The pt denied headache, loss of vision, blurred vision,
diplopia, shortness of breath, chest pain or tightness,
palpitations.
Past Medical History:
1. HTN
2. OA
3. s/p hysterectomy
Social History:
Lives at [**Hospital3 **] facility and denies EtOH or illicit
drugs. Former smoker of unknown number of pack years.
Family History:
stroke
Physical Exam:
Temp: 96.7; BP: 160/64; HR: 63; RR: 16; SaO2: 98% 2LO2
Gen: Alert, oriented. Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Neuro:
>>MS??????Alert. Oriented to self, location, date. Vague historian.
Speech fluent, dysarthric. No paraphasic errors. Registration,
repetition, recall intact. Able to read, name.
>>CN??????PERRL. Decreased threat blink on left field but able to
identify objects correctly in Cookie Theft picture. however does
not identify neurologists in left visual field until verbal cue
proffered. No ptosis. EOMI w/ smooth pursuit. Facial sensation
and pterygoid strength intact. Moderate left facial weakness.
Hearing intact to finger rub. Palate elevates midline. Tongue
protrudes midline.
>>Motor??????R UE [**5-27**]. L UE [**5-27**] except 5-/5 in triceps, WE, grip. R
LE [**5-27**]. L LE [**5-27**]. No drift. Tone normal.
>>Sensory??????Light touch, temp, pinprick and vibration intact.
Left sided DSSE. Graphesthesia intact.
>>DTRs??????L/R: bic [**2-24**], br [**2-24**], tri [**1-23**]; pat [**2-24**], Ach 0/0. Plantars
bilaterally flexor.
>>Cerebell-No dysmetria, no dysdiadochokinesia.
1a LOC =0
1b Orientation =0
1c Commands =0
2 Gaze =0
3 Visual Fields =1
4 Facial Paresis =2
5a Motor Function R UE =0
5b Motor Function L UE=0
6a Motor Function R LE=0
6b Motor Function L LE=0
7 Limb Ataxia =0
8 Sensory perception =0
9 Language =0
10 Dysarthria = 1
11 Extinction/Inattention =1
TOTAL = 5
Pertinent Results:
[**2183-2-18**] 02:18AM BLOOD WBC-9.3 RBC-4.14* Hgb-12.5 Hct-36.2
MCV-88 MCH-30.1 MCHC-34.4 RDW-14.4 Plt Ct-281
[**2183-2-18**] 02:18AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-141
K-3.3 Cl-110* HCO3-24 AnGap-10
[**2183-2-17**] 07:41PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2183-2-18**] 02:18AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2183-2-18**] 02:31PM BLOOD cTropnT-0.10*
[**2183-2-18**] 02:18AM BLOOD %HbA1c-6.2*
[**2183-2-18**] 02:18AM BLOOD Triglyc-83 HDL-74 CHOL/HD-2.7 LDLcalc-112
CT HEAD p IV tPA: No hemorrhage; subtle hypodensity involving
the right inferior frontal lobe may represent infarction.
CAROTID US:
1. No significant ICA stenosis on either side.
2. Antegrade flow in both vertebral arteries.
Echo: Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Moderate
mitral regurgitation.
Brief Hospital Course:
Patient is a [**Age over 90 **] y/o woman with report of sudden onset left
hemiparesis w/ forced gaze deviation and neglect, s/p IV tPA at
OSH transferred here for further care. On exam at arrival, she
had left tactile>visual neglect and less prominent dysarthria
and appendicular weakness. Repeat head CT (~3h s/p initial
images) does not clearly show progressive ischemia.
Symptoms most strongly suggested right parietal dysfunction, in
light of prominent visual/sensory symptoms and evanescent motor
symptoms. Ischemia is quite possible; significant clinical
resolution is already apparent. However, alternative
etiologies, such as seizure, may need to be considered given no
clear imaging evidence of ischemia and significant improvement.
She was initally admitted to the ICU given IV tPA where she
remained stable with repeat CTs showing no hemorrhagic
transformation. She was successfully transferred to neurology
floor service the next day where she continued to have clinical
improvement of symptoms including improvement of strength and
dysarthria on L side. MRI was tried but patient did not
tolerate it and refused repeat studying. To rule out possible
underlying pathology (e.g. tumor), CT of head with contrast was
obtained. Rest of stroke work-up was also done including
surface echocardiogram (normal EF, no thrombus), carotid US (0%
and < 40% stenosis on R and L respectively).
She was evaluated per PT/OT during this admission who
recommended services at the [**Hospital3 **] facility where she
was residing prior to the admission. She will be following up
with Dr. [**Last Name (STitle) **]/[**Doctor Last Name 78537**] (neurology) as outpatient and she was
started on Simvastatin for cholesterol control in addition to
changing aspirin to Plavix.
Medications on Admission:
1. Amlodipine 5 mg Daily
2. Cozaar 50 mg Daily
3. Aspirin 81 mg Daily
4. Multivitamin Once Daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Cozaar 50 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for SBP < 100 .
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100 .
5. Multi-Day Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Stroke - R frontal stroke s/p IV tPA
Discharge Condition:
Stable - ambulatory with minimal assistance/walker, slight L
facial droop but fluent speech and no sensory deficit.
Discharge Instructions:
You were transferred from outside hospital after presenting with
acute L sided weakness and gaze deviation hence receiving IV tPA
for acute ischemic stroke. Upon arrival, your symptoms were
already improving including increased strength and resolution of
your gaze deviation. Given that you received IV tPA, you were
initially admitted to the ICU where you remained stable
including vital and you were transferred to the neurology floor
service the next day for completion of you stroke work-up.
You did not tolerate MRI of brain but repeat CTs including CT
with contrast shows small R frontal stroke. You had ultrasound
of your carotids and your heart with normal results. Your LDL
cholesterol was 112 (ideally < 100) hence you were started on
Simvastatin 20mg daily. Given that you had a stroke while you
were taking aspirin, your aspirin was replaced with Plavix for
better stroke prevention.
Please take your meds as prescribed. Please follow-up with Dr.
[**Last Name (STitle) 5057**] (your PCP) within 2~3 weeks of discharge to ensure good
control including BP. You have been scheduled to follow-up with
Dr. [**Last Name (STitle) **] (neurology) on [**2183-3-26**] at 3pm at [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **].
Please call your doctor or go to the nearest ED if you have
worsening weakness or speech problems, new weakness or severe HA
and/or visual problems.
You were evaluated by occupational and physical therapists
during this admission who recommends discharge back to your
[**Hospital3 **] facility with home PT.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2183-3-26**] 3:00 - [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Please follow-up with Dr. [**Last Name (STitle) 5057**] (your PCP) within 2~3 weeks of
discharge to ensure good control including BP.
Completed by:[**2183-2-26**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4445
} | Medical Text: Admission Date: [**2151-5-13**] Discharge Date: [**2151-5-21**]
Date of Birth: [**2109-12-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Femoral and right internal jugular central line placement
History of Present Illness:
41 year-old morbidly obese male with hx of progressively
worsening lymphadema, hx of abnormal LFT's, enlarged liver on CT
([**2149-12-4**]) who presented to the [**Hospital 1560**] clinic today for a
pre-op evaluation for possible gastric bypass surgery who was
referred to the ED after noted to have wheezing and dyspnea. In
terms of lymphadema, he has gained 180lbs in the last 2 years.
He is being followed by [**Hospital 59973**] clinic. He is able to
ambulate with assistance but spends most of his time sleeping
and watching TV. In terms, of his LFT's an liver enlargment, he
was told that he has a fatty liver. For his lymphadema, he was
taking Lasix 20-30 mg po qd until 15 days ago when he self-D/C'd
since it was not working. Pt noticed SOB today and wheezing
today, and never had this before. His wife also reports that he
has been bruising more easily.
.
In the ED, his CXR was noted to be in mild CHF, EKG with sinus
tach but no R-side strain. He was afebrile, normotensive
140/70, and O2sat 97% RA. D-dimer was 3425 but was unable to
get CTA due to orthopnea and also due to body habitus. He got
albuterol and IV lasix 40 mg, and felt better after having
~800cc UOP. He also received KCl 60 meq x 2, and Ceftriaxone.
Since the suspicion for PE was high, he was empirically started
on Heparin drip. He was ordered for RUQ U/S and LENI but could
not get in the ED due to tenuous respiratory status.
.
He was transferred to the floor. When he was carried from the
stretcher to the chair, he desaturated to 77% on RA and appeared
cyanotic. He started to shake, but after giving him 100% NRB,
his O2sat immediately came up to 99% and was able to wean down
to 4LNC. When he was transferred from the chair to the bed, he
again became cyanotic, unresponsive, and had a seizulre like
activity. Code was then called. He was given 100% NRB but
difficult to check the O2sat. Initially, it was difficult to
palpate his pulse and measure his BP. He was given up to 8 mg
ativan. Initially the team was unclear if a pulse was present.
There was also a delay of several minutes obtaining a blood
pressure as there were no appropriate sized cuffs. However SBP
subsequently noted to be in 180s. There was a concern for
bradycardia at one point (though per team in retrospect ?related
to lead displacement)--> received atropine 1 mg and epinephrine
1 mg with a HR response to 130s and SBP to 180s. An ABG showed
6.9/118/107 on unclear amount of O2 prior to intubation, which
was difficult. He then received 1 amp HCO3 for this acidosis. A
later ABG was 7.12/85/232 shortly after intubation. Stat cardic
echo showed no evidence of RV collapse or RH strain.
Past Medical History:
- morbid obesity
- chronic LE lymphedema
- hepatic mass
- chronic transaminitis: CT of liver described as "fatty" per pt
Social History:
Pt lives in [**Location **] with his wife (they have no children). They
have cats. He worked as a horticulturalist for [**Street Address(1) 59974**]
Service until [**2150-7-5**] when he stopped working because of his
worsening lymphedema. He smokes ?????? pack a day and has smoked for
20 years. He does not drink any alcohol anymore. He stopped
approximately six months ago when he found out he had a fatty
liver (he had been drinking a six pack a day). Pt has not used
any recreational drugs since he used marijuana and cocaine in
high school.
Family History:
Pt??????s father is 82. [**Name2 (NI) **] had an MI at 65 and has emphysema (even
though he only smoked for several months). Pt??????s mother is 80 and
she has asthma and arthritis. An aunt died of colon cancer. No
history of liver problems or lymphedema in family.
Physical Exam:
(prior to code): T 98 BP 140/70 HR 80 RR 20 O2sat 97% RA
GEN: Morbidly obese, +rigor, occasionally cyanotic peri-oral
area
HEENT: +right subconjunctival hemorrhage, anicteric sclera,
PERRL, EOMI, MMM
Neck: large, no LAD, no visible JVD
COR: RRR, distant S1, S2, no M/R/G
LUNGS: +bilateral wheezes
ABD: obese, visible lichenified, venous static change in the
lower abdomen
EXT: Extremley large, thick skin, lymphadema. Warm to touch R>L
LE, erythematous warm area on the Right poterior calf.
Brief Hospital Course:
ICU Course:
Patient was transferred to the MICU for respiratory failure. He
was intubated and wa empirically treated for CHF, pneumonia, and
possible PE. He was on Heparin gtt but was discontinued after
severe oral/tongue bleed. He got echo which showed enlarged LA,
EF 50-60%, mild symmetric LVH, dilated RV cavity. He started to
get diuresed with standing lasix and later to lasix drip. He is
negative 1.8 L during the ICU stay and his respiratory status
improved accordingly. He likely was volume overloaded as he
self-D/C'd po lasix at home, and had increased RV pressure ->
right side failure -> LV dysfuncton from interventricular septal
effect. He likely has chronic hypercarbia from OSA. He got right
IJ placed. In terms of vent, he was able to wean to PSV on [**5-15**],
did well on spontanenous breathing trial on [**5-16**], and self
extubated on [**5-16**]. He was stable on 2 L nasal canula when he was
called out to the floor.
Floor Course by System:
1)CHF: He likely has significant right side failure from obesity
and OSA. The echo showed EF>55% but dilated RV and mild
symmetric LVH. Pt got aggressive diuresis in the ICU. When he
was getting IV lasix 60 mg [**Hospital1 **], he got diuresed total of 8 L.
Lasix regimen was eventually titrated to po Laix 60 mg [**Hospital1 **] which
he was able to diureses about [**Telephone/Fax (1) 1999**] ml/day. He got an
intruction by the team and the nutritionist regarding the low
sodium diet and fluid restriction. He was started on Metoprolol
25 mg [**Hospital1 **] and Lisinopril 5 mg qd for his heart failure. He will
follow up with Pulmonary/Sleep [**Hospital **] clinic for his presumed
sleep apnea which is likely contributing to his right side heart
failure. He tried BIPAP as well as CPAP on the floor and
tolerated well. We have lended him a CPAP machine to be used at
home until he gets his own machine arranged after the sleep
study. He was instructed to weigh himself daily but since he
weighs >400 lb, he does not have a big enough scale to measure
him. He was told to return to the ED if he notices worsening LE
edema or SOB. Prior to discharge, he was able to ambulate on
his own without oxygen. His O2sat was 96-97% on RA at rest.
2)Fever: Pt had a new fever on [**5-18**]. Likely from line infection
as femoral line tip showed coag neg staph. Both the femoral and
the IJ line were pulled. He was initially on Vancomycin but as
the blood culture from [**5-18**] showed no growth, Vanc was
discontinued. He continued to have intermittent low grade
temperature to 100.3. CXR showed no pneumonia and UA was clean.
He was discharged without any antibiotics and was told to come
back if he spikes a fever.
3)Lympahdema: Likely from his right side heart failure which has
been neglected for years. He notes that he has gained about 200
lb over the last 2 years. This is likely from his right side
failure in addition to high salt/fluid intake. With his new
regimen of Lasix 60 mg [**Hospital1 **], hopefully he would gradually be able
to diurese his total excess body weight.
4)Pain: Pt with musculoskeletal pain on his right side, likely
from the code. Hip film negative for fracture or dislocation on
both hips. He was given NSAIDS and morphine for pain. He also
noted right side sciatic pain. He has a chronic back pain and
he may have had worsening disc herniation during the code. He
will have home PT.
5)Liver: He carries a diagnosis of "fatty liver" and
hepatomegaly seen on the CT scan from [**Month (only) 404**]. His AFP was
elevated at 12 and LFT's were ALT 29 AST 181 LDH 605 ALK
PHOS-376 TOT BILI 4.1. It is unclear whether his hepatomegaly
is from hepatic congestion from the right side heart failure or
he has a developing liver mass. Since he was too large to get
the CT scan, we were not able to reassess his liver size on CT.
He will follow up with the Liver Center on [**5-26**].
Medications on Admission:
Celexa 20 mg po qd, "allergy pills", ASA, MVI
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*30 Tablet(s)* Refills:*0*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QAM, AND
Q4PM ().
Disp:*180 Tablet(s)* Refills:*2*
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-6**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
9. CPAP
CPAP
Autoset, 7-14 cm's, heated humidifier, mask to fit
10. Potassium Chloride 20 mEq Packet Sig: Two (2) PO once a
day.
Disp:*60 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Primary:
1)Right side congestive heart failure
Secondary:
1)Likely sleep apnea
2)Hepatomegaly
3)Lymphadema
Discharge Condition:
Hemodynamically stable, able to ambulate on his own without
oxygen.
Discharge Instructions:
Please take all of the medications as directed. Please limit
your fluid intake to 1.5L/day. Please weight yourself daily if
possible. Please notify your PCP if you gain more than 5 lbs
from the weight on the discharge day. Please adhere to the low
sodium diet. Please follow up with all of the scheduled
appointments. Please seek medical attention if you develop
fever, chills, shortness of breath, chest pain, increased
weight, worsening lymphadema, or any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2151-5-26**] 10:00
[**Hospital 191**] clinic will call you with an appointment with Dr. [**First Name (STitle) **]
within 2-4 weeks. Please call [**Telephone/Fax (1) 250**] to confirm the date.
You have an appointment with Dr. [**Last Name (STitle) **] in the Pulmonary/Sleep
Medicine on [**2151-5-27**] at 10:00 AM. [**Location (un) 858**] [**Hospital Ward Name 23**] building.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2151-5-27**] 10:00
Completed by:[**2151-5-23**]
ICD9 Codes: 2762, 2851, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4446
} | Medical Text: Admission Date: [**2188-3-13**] Discharge Date: [**2188-3-28**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
1. GI bleeding
2. Orthopnea
3. Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2188-3-14**]: Left PICC placement
[**2188-3-17**]: Mesenteric Arteriogram with Uncomplicated Embolization
of distal branch with three microcoils.
[**2188-3-18**]: MESENTERIC ARTERIOGRAM
[**2188-3-18**]: Exploratory laparotomy, left colectomy, splenic
flexure takedown, transgastric feeding gastrojejunostomy, end
colostomy, Hartmann's creation.
History of Present Illness:
Mr. [**Known lastname 17766**] is a [**Age over 90 **] year old male with past medical history
significant for HTN, atrial fibrillation, hyperlipidemia, and
BPH.
The patient noticed "bloody diarrhea" and "spurting" BRBPR which
started yesturday. Patient presented to the OSH and was noted to
have HCT 21. Unclear baseline HCT given limited records at this
time. Patient also complaining of extreme weakness x 1 week. He
denies any associated abdominal pains, nausea, emesis or fevers.
Recent poor appetite and 20 lb. weight loss x 2 months also
reported. At OSH he o had presumed acute renal failure with Cr
in 2.6 range, and elevated potassium to 6.3. He was given
combination of low dose IV Insulin, Ca gluconate, bicarbonate
and IV dextrose for this hyperkalemia at OSH and repeat labs
here at [**Hospital1 18**] ED showed potassium down to 5.1. EKG at OSH
showing atrial fibrillation with rate 90s and ST depressions in
V5-V6.
.
Mr. [**Known lastname 17766**] has history of known atrial fibrillation and states
he was taking Coumadin in the past but in recent months he has
been taking 325mg daily aspirin instead. He explains that this
change to ASA was due to hematuria from "benign bladder lesions"
a few months ago. He has also been taking [**3-11**] 400mg ibuprofen
tablets daily for pain over his right heel from a deep skin
ulcer. He denies ever having any prior GI bleeds in the past. No
prior colonoscopies per patient. Denies any prior MIs or PEs.
.
Per reports from OSH and [**Hospital1 18**] ED he has not had any dizziness
or significant hypotension despite his atrial fibrillation and
acute anemia from GI losses.
In the [**Hospital1 18**] ED, initial vitals were: T 96.4F, RR 18-20, O2
Saturation 96% NRB 10L, BP 127/60. CXR showed mild fluid over
bases ( R>L). Labs in ED notable for a HCT of 24.4, Cr 2.4
(assumed ARF but unknown baseline). Troponin elevated to .64 and
CK 504, CK MB 65. Patient denies any chest pains, shortness of
breath or palpitations.
In ED he was given 2L NS IVFs and 1 Unit PRBC (also got 1 Unit
PRBCs en route from [**Hospital3 **]). NG lavage was negative in ED and
rectal exam grossly guaiac positive. GI saw patient in ED and
advised IV PPI, PRBCs and IVFs with plan for colonoscopy in [**12-8**]
days as long as patient remains stable.
.
On arrival to ICU, patient appeared pallid and weak but was in
no acute distress. Fully alert and oriented but history of
specific medication doses challenging. He continued to deny CP,
SOB, dizziness or abdominal pain but did endorse feeling
extremely fatigued
Past Medical History:
-Hypertension
-Hyperlipidemia
-benign bladder tumors
-atrial fibrillation
-distant h/o gout in right LE
-BPH
Social History:
Patient lives with his wife in [**Hospital3 4298**]. Wife has
[**Name2 (NI) 11964**]. He is retired broadcast manager. Drinks 1 glass wine
daily. Prior tobacco use, smoked 1PPD x 40 years and quit at age
60. No illicit drug use.
Family History:
Brother died at age 57 from MI. No family history of colon
cancer, UC/Crohns
Physical Exam:
On Admission:
GENERAL: alert and oriented x3, NAD, pleasant
HEENT: PERRL, EOMI, dry MM. OP clear with fair dentition but
missing teeth.
NECK: JVP at 6cm, supple, no LAD, no thyromegaly
CARDIAC: S1/S2 regular, irregularly irregular rhythm. No
murmurs, rubs or gallops appreciated.
LUNG: Mild Bibasilar crackles ( right>left)
ABDOMEN: Normoactive bowel sounds throughout, nontender with no
rebound or guarding. Nondistended. No HSM. Rectal with gross BRB
/ (hemoccult positive in ED)
EXT: 2+ pedal pulses, quarter-sized ulcer over right heel with
partial scab, no edema noted
NEURO: CNs [**1-18**] grossly in tact. Sensation in tact throughout.
Deferred gait assessment.
SKIN: wound on right heel as above, no other rashes or bruising,
pallid complexion
On Discharge:
VS: Afebrile, VSS
general: Alert, awake and oriented x 3, NAD
Head: NC/AT
Neck: Supple, JVP at 4 cm
Cardiac: Irregularly irregular, normal S1/S2
Lungs: CTAB
Abdomen: Soft, nondistended. Midabdominal incision with surgical
staples, open to air and clear/dry and intact. RLQ stoma,
necrotic with brown output. J/G tube site with dry dressing,
c/d/i
Extr: 2+ pedal edema, 1+ pedal pulses, right heel vascular ulcer
with dry dressing.
Neuro: PERRL, EOMI, Tongue protrude midline, Follows all
commands.
Pertinent Results:
[**2188-3-13**] 10:17PM TYPE-ART PO2-101 PCO2-31* PH-7.44 TOTAL
CO2-22 BASE XS--1
[**2188-3-13**] 10:17PM LACTATE-1.5
[**2188-3-13**] 08:04PM GLUCOSE-115* UREA N-66* CREAT-2.5* SODIUM-140
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-19* ANION GAP-24*
[**2188-3-13**] 08:04PM ALT(SGPT)-396* AST(SGOT)-893* ALK PHOS-56 TOT
BILI-1.3
[**2188-3-13**] 08:04PM CALCIUM-9.7 PHOSPHATE-7.4* MAGNESIUM-2.4
[**2188-3-13**] 08:04PM WBC-13.0* RBC-3.02* HGB-9.3* HCT-27.5*
MCV-91# MCH-30.7 MCHC-33.7 RDW-16.1*
[**2188-3-13**] 08:04PM NEUTS-93* BANDS-2 LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-3-13**] 08:04PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
BURR-1+
[**2188-3-13**] 08:04PM PLT SMR-NORMAL PLT COUNT-176
[**2188-3-13**] 08:04PM PT-15.2* PTT-26.5 INR(PT)-1.3*
[**2188-3-13**] 04:00PM WBC-10.5 RBC-2.47* HGB-7.8* HCT-24.4* MCV-99*
MCH-31.6 MCHC-32.0 RDW-14.9
[**2188-3-13**] EKG: Artifact is present. Probable sinus rhythm with
atrial ectopy. Low voltage in the limb leads. No previous
tracing available for comparison.
[**2188-3-13**]: CHEST X-RAY:
IMPRESSION: Moderate-sized right pleural effusion with right
basilar
atelectasis, but infection cannot be excluded.
[**2188-3-14**] 04:37AM BLOOD WBC-13.1* RBC-3.45* Hgb-10.3* Hct-31.3*
MCV-91 MCH-30.0 MCHC-33.0 RDW-16.9* Plt Ct-130*
[**2188-3-14**] 11:48AM BLOOD Glucose-96 UreaN-69* Creat-2.7* Na-141
K-5.6* Cl-108 HCO3-18* AnGap-21*
[**2188-3-14**] 11:48AM BLOOD ALT-547* AST-958* LD(LDH)-800*
CK(CPK)-825* AlkPhos-50 TotBili-1.2
[**2188-3-14**] 07:50PM BLOOD CK-MB-54* MB Indx-7.9* cTropnT-1.85*
[**2188-3-14**] 04:37AM BLOOD Calcium-8.3* Phos-6.3* Mg-2.2 Cholest-103
[**2188-3-14**] 04:52AM BLOOD Type-ART pO2-229* pCO2-25* pH-7.41
calTCO2-16* Base XS--6
[**2188-3-14**]: PORTABLE TTE:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
extensive regional systolic dysfunction c/w multivessel CAD.
Moderate pulmonary artery systolic hypertension. Mild-moderate
mitral regurgitation. Moderate to severe tricuspid
regurgitation. Increased PCWP.
[**2188-3-14**] EKG:
Probable sinus rhythm with frequent atrial ectopy. The Q-T
interval is
prolonged. Low voltage in the limb leads. Non-specific ST-T wave
changes.
Compared to the previous tracing Q-T interval prolongation and
ST-T wave
changes are new.
[**2188-3-14**] CHEST X-RAY:
IMPRESSION: Suggestion of a moderately large right pleural
effusion,
including a subpulmonic effusion. A right lateral decubitus view
may be
helpful in further characterization.
[**2188-3-14**] RENAL U.S.:
IMPRESSION:
1. Unremarkable renal ultrasound with no evidence of
hydronephrosis.
2. Right-sided pleural effusion.
[**2188-3-17**] EKG:
Atrial fibrillation. Low limb lead QRS voltage is non-specific.
Diffuse
ST-T wave abnormalities are no-specific but cannot exclude
ischemia. Clinical correlation is suggested. Since the previous
tracing of the same date no significant change.
[**2188-3-17**] MESENTERIC ARTERIOGRAM :
IMPRESSION: Selective arteriogram of the inferior mesenteric
artery demonstrating active extravasation of contrast material
from a distal branch within the descending colon.
Uncomplicated embolization of this branch with three microcoils.
[**2188-3-18**] ARTERIOGRAM:
IMPRESSION:
1. Selective arteriogram of the celiac, and superior mesenteric
artery
demonstrate no evidence of active extravasation.
2. Selective arteriogram of the inferior mesenteric artery was
performed.
During procedure initial impression was that there is no
definite evidence of active extravasation. On morning review of
the images, there is a small
questionable focus of contrast pooling beyond the site of prior
coil
placement; however considered not amenable to further
embolization due to
high risk of colonic infarction.
[**2188-3-18**] CHEST X-RAY:
FINDINGS: Compared to the previous examination done at 10:20
a.m. on [**3-17**], a Swan-Ganz catheter has been placed. Its tip lies in the
main pulmonary artery. ET tube tip lies 4.2 cm above the carina
and is satisfactory. NG tube tip lies in the stomach but the
sideport is at the GE junction. This tube should be advanced
another 5-8 cm. Bilateral pleural effusions, right greater than
left which obscure evaluation of the lung fields. Note is made
of a dilated loop of bowel, likely colon in the small portion of
the visualized abdomen on this chest x-ray.
[**2188-3-20**]: ABDOMEN U.S:
FINDINGS: The liver demonstrates no concerning focal
abnormalities. There is no intra- or extra-hepatic biliary
dilatation with the common bile duct
measuring up to 4 mm. Incidentally noted is a hepatic cyst seen
within the
left lobe measuring 1.0 x 0.9 cm. The main portal vein is patent
with
appropriate hepatopetal flow. There is cholelithiasis and sludge
within the gallbladder. There are no secondary signs of
cholecystitis with no
gallbladder wall thickening. There is a negative son[**Name (NI) 493**]
[**Name (NI) **] sign.
There is no pericholecystic fluid. Note is made of bilateral
pleural
effusions. The spleen is normal in size measuring up to 9.2 cm.
[**2188-3-21**] CHEST X-RAY:
FINDINGS: In comparison with the study of [**3-19**], the endotracheal
and
nasogastric tubes have been removed. Persistent bilateral
pleural effusions, more prominent on the right. Swan-Ganz tube
has been removed and only the right IJ sheath remains. Continued
mild cardiomegaly and aortic tortuosity with some elevation of
pulmonary venous pressure. Prominent lucency in the upper
abdomen, again most likely represents either postoperative
pneumoperitoneum or a dilated colonic loop. Abdomen image would
be helpful for making this distinction.
[**2188-3-23**] ABDOMEN X-RAY:
IMPRESSION: Two views include most of the chest and upper
abdomen, and the
pelvis. Bilateral pleural effusions are moderate size and
dependent. Lung bases are partially atelectatic. Upper lungs are
clear. The heart is mildly enlarged. There is no pneumothorax. A
large bore right supraclavicular central venous line ends in the
region of the brachiocephalic confluence. A left PIC catheter
can be traced to the upper SVC. The full course of the
gastrojejunostomy tube cannot be followed because of
discontinuity in the fields of view, but there is a loop of
tubing projecting over the stomach and one end projecting over
the right lower abdomen. Skin staples denote recent abdominal
surgery in the right lower quadrant. A drain projects over the
left half of the pelvis. I cannot tell if this is a urinary
catheter or not. There is no pathological distention of the
intestinal tract. Whether there is free subdiaphragmatic gas is
indeterminate. Heavy atherosclerotic calcification is present in
the iliac arteries. A sclerotic lower lumbar vertebral body may
represent metastatic prostate carcinoma.
[**2188-3-24**] CHEST X-RAY:
IMPRESSION: AP chest compared to [**3-23**]:
Right internal jugular line ends in the low SVC. Moderate left
and
moderate-to-large right pleural effusion have decreased, and
there is no
pulmonary edema. Left lower lobe is chronically airless. Heart
size is
normal. No pneumothorax.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 86856**],[**Known firstname **] [**2096-1-7**] [**Age over 90 **] Male [**Numeric Identifier 86857**]
[**Numeric Identifier 86858**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: left colon.
Procedure date Tissue received Report Date Diagnosed
by
[**2188-3-18**] [**2188-3-18**] [**2188-3-21**] DR. [**Last Name (STitle) **]. BROWN/mrr??????
DIAGNOSIS: Left colon, colectomy (A-H):
Diverticular disease with very focal active inflammation and
focal peridiverticular chronic inflammation and fibrosis
consistent with diverticulitis.
Brief Hospital Course:
[**Age over 90 **]-year-old male with PMH significant for HTN, atrial
fibrillation ( on home ASA), and hyperlipidemia who presented
with LGIB, NSTEMI and ARF in setting of hypovolemia & severe
anemia with HCT drop to 21 range.
* GI Bleeding
Patient was admitted to the MICU, initially stable without
further episodes of BRBPR. GI planned colonoscopy and he was
transferred to the floor. There, he experienced multiple
episodes of BRBPR with hypotension necessitating readmission to
the MICU and hemodynamic resuscitation with blood products and
fluids. GI felt that given his significant bleeding, endoscopy
would provide only limited information and recommended
angiography with interventional radiology. This study showed [**Female First Name (un) 899**]
branch bleeding and he underwent coiling. However, back in the
ICU he continued to have large amounts of BRBPR necessitating
further transfusions. He was evaluated by the surgery service
who recommended exploration in the OR and colectomy. After
discussion of the risks and benefits of this procedure including
cardiac risk in setting of NSTEMI, patient and his family
elected to proceed with surgery. On [**2188-3-18**], the patient
underwent exploratory laparotomy, left colectomy, splenic
flexure takedown, transgastric feeding gastrojejunostomy,
endcolostomy, and Hartmann's creation, which went well without
complication (reader referred to the Operative Note for
details). After surgery, patient was transferred back in the
MICU intubated, with an NG tube, on IV fluids and antibiotics,
with a foley catheter and a JP drain in place, and on Versed
and Fentanyl for pain control and sedation. Patient was
successfully extubated on [**3-19**], and his pain medication was
changed to Dilaudid IV prn. Intraoperativelly patient received 3
units of pRBC. Post surgery he was transfused with 2 more units
of RBC for Hct 24.7, patient's Hct increased to 33.7 and
continue to be stable since [**3-19**]. Last Hct result was obtained
on [**3-26**] and was 31.3.
* CAD with NSTEMI
Patient's cardiac enzymes were elevated, with CKs peaking in the
800's. He was evaluated by the cardiology service medically
managed with aspirin and metoprolol, which were both later held
in the setting of large rebleeding. Patient had a transient rise
in his CKMB index which is now trending down, as well as
positive troponins. This elevation in his cardiac enzymes is
most likely the resulted of demand ischemia in the setting of a
fixed coronary artery obstruction, rather than a true acute
coronary syndrome from unstable plaque rupture. TTE also
supports the diagnosis of asymptomatic multivessel CAD. After
patient's Hct level stabilized above 30s, his cardiac status
remained stable. He continue to receive 325 mg of Aspirin, and
he restarted his home medication (Nifedipine and Nadolol) on
discharge. Patient will follow up with his PCP after discharge.
* Systolic CHF, chronic
Patient's baseline EF was unknown. TTE here showed EF 30-35%,
mild LVH, extensive regional systolic dysfunction c/w
multivessel CAD, 1+ AR, [**1-9**]+ TR. He was initially treated with
low dose metoprolol and captopril which were held in the setting
of subsequent hemodynamic instability. He will need close
monitoring of weights and volume status. Patient's history of
dyspnea on exertion and orthopnea consistent with chronic
systolic CHF, Class II. On admission patient had moderate
pleural effusion, but his lungs were clear to auscultation and
he was able to lie flat with a minimal oxygen requirement.
Patient received IV fluid resuscitation and multiple blood
product transfusions during hospital stay. Pulmonary status was
monitored closely with daily physical examinations and chest
x-rays. Patient was given Lasix prior blood transfusions to
prevent fluid overload. Chest x-ray from [**3-24**] demonstrated
bilateral moderate-to-large pleural effusion right greater than
left with bibasilar atelectases b/l. Patient's O2 Sats 95-98% on
RA, and he doesn't requires any supplemental O2 on discharge.
* Acute kidney injury
Patient's creatinine was elevated at admission, felt likely due
to prerenal state. This improved following blood product and
fluid resuscitation. Patient's Cre was 3.9 max and trending
down, currently 2.7([**3-28**]).
* Atrial fibrillation
The patient had previously been on warfarin, which had been
stopped as an outpatient due to hematuria (due to "benign
bladder tumors" per patient). His aspirin was held in the
setting of significant GI bleeding. He was initially treated
with metoprolol without episodes of RVR. Patient continue to
have rate controlled A-fib with HR 70-90s. Patient was restarted
on his home meds (Nifedipine and Nadolo) prior discharge.
Cardiology recommended to reassess Coumadin in the future per
patient's PCP.
* HTN
Patients home antihypertensives were held in setting of
bleeding. Once stabilized, may start metoprolol and low dose
ACEI as BP tolerates. Blood pressure remained stable
postoperativelly, SBP 110-120s.
* Heel wound
This was evaluated by the wound care RN and treated with local
care. Further evaluation for PVD is suggested. Vascular surgery
was consulted, patient will follow up with Dr. [**Last Name (STitle) **] on [**4-11**].
Currently patient continue on hydrogel daily with dry dressing.
During this hospitalization, the patient was evaluated by
Physical Therapy,and was recommended discharge in rehabilitation
facility to continue PT. Patient was
adherent with respiratory toilet and incentive spirrometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient's blood sugar was monitored regularly
throughout the stay; sliding scale insulin was administered when
indicated. Labwork was routinely followed; electrolytes were
repleted when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, 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:
Nifedipine 60', Nadolol 40', ASA 325', Flomax .4', 400mg
ibuprofen PO 4-6 tablets daily, colchicine
Discharge Medications:
1. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
5. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for ulcer.
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units
5000 units Injection three times a day: SC TID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
1. Lower gastrointestinal bleeding.
2. Atrial fibrillation
3. CHF
4. CAD with NSTEMI
5. Right heel ulcer
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:
General Discharge Instructions:
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 [**4-14**] 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.
*Please remove staples from midabdominal incision on [**2188-4-1**].
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
J/G tube 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 warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change 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.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2188-4-11**] 11:30. [**Last Name (NamePattern1) **], Vascular surgery
clinic
.
2. Please call your PCP to arrange [**Name Initial (PRE) **] follow up appointment in
[**1-9**] weeks after discharge
.
3. Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment
with Dr. [**First Name (STitle) 2819**] (General Surgery) in [**1-9**] weeks after discharge
Completed by:[**2188-3-28**]
ICD9 Codes: 5849, 2851, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4447
} | Medical Text: Admission Date: [**2122-11-23**] Discharge Date: [**2122-12-6**]
Date of Birth: [**2050-8-14**] Sex: M
Service: CARDIAC
HISTORY OF PRESENT ILLNESS: This is a 72 year old white
male who has a new onset of left arm pain and nausea and
ruled out for an myocardial infarction. He was transferred
from the cardiac catheterization laboratory. He has a
history of hypertension and presented to the [**Hospital6 3426**] on [**11-21**] with left arm pain associated with nausea,
belching and flatus. He reports the pain awoke him from
sleep. He denies shortness of breath or palpitations. He
became pain free in the Emergency Room without intervention.
Initial enzymes were negative and the electrocardiograms had
no ischemic changes.
He underwent a spec MIBI on [**11-22**] which was suggestive of
infarction along the inferior wall. The patient remained
pain free and was transferred to [**Hospital1 190**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Status post excision of melanoma from the chest.
2. History of borderline hypertension.
3. History of gout.
4. History of allergic rhinitis.
5. Status post appendectomy.
6. Status post left hernia repair.
7. Status post bilateral rotator cuff surgery.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day.
2. Hydrochlorothiazide 25 mg p.o. q. day.
3. Protonix 40 mg p.o. q. day.
4. Probenecid 250 mg p.o. q. day.
5. Chondroitin.
REVIEW OF SYSTEMS: His review of systems is unremarkable.
SOCIAL HISTORY: He drinks three to four drinks per night.
He lives at home with his wife. [**Name (NI) **] smoked half a pack a day
and quit forty years ago.
PHYSICAL EXAMINATION: On physical examination, he is a well
developed, well nourished white male in no apparent distress.
Vital signs were stable. HEENT examination normocephalic,
atraumatic. Extraocular movements intact. Oropharynx
benign. Neck was supple, full range of motion, no
lymphadenopathy or thyromegaly. Carotids were two plus and
equal bilaterally without bruits. Lungs were clear to
auscultation and percussion bilaterally. Cardiovascular was
regular rate and rhythm with normal S1, S2 with no rubs,
murmurs or gallops. Abdomen was soft, nontender, with
positive bowel sounds, no masses or hepatosplenomegaly.
Extremities without cyanosis, clubbing or edema.
Neurological examination was non-focal. Pulses were two plus
and equal bilaterally throughout.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**11-23**], which revealed that left ventricle
had one plus mitral regurgitation and had a normal ejection
fraction. The left main had a 60 to 70% ostial lesion and a
60% distal lesion. Left anterior descending had an ostial of
30% lesion, mid of 60% lesion, left circumflex was calcified
and occluded at the mid vessel and the right coronary artery
had proximal tapering with diffuse luminal irregularities to
a maximum stenosis of 30%.
Dr. [**Last Name (STitle) 70**] was consulted and on [**2122-11-25**], the patient
underwent a coronary artery bypass graft times two with left
internal mammary artery to the left anterior descending and
reverse saphenous vein graft to obtuse marginal 1.
Crossclamp time was 37 minutes. Total bypass time 52
minutes. He was transferred to the CSRU on Neo-Synephrine
and Propofol in stable condition.
He had a stable postoperative night and he was extubated. He
became confused on postoperative day number two. He was on
neo-synephrine which was weaned off. He also had a
temperature to 101.8 F. He was cultured. He was started on
beer. On postoperative day three, he had his chest tubes
discontinued. He also was in atrial fibrillation.
He had a tachy-brady syndrome and they recommended observing
him. He also had some atrial fibrillation and was started on
amiodarone no acute distress converted to sinus rhythm. He
was transferred to the floor on postoperative day number five
and electrophysiology saw him again and recommended
discontinuing the amiodarone due to his bradycardic episodes,
and he also was anti-coagulated with heparin and then
Coumadin. He had his wires discontinued on postoperative day
number six.
He continued to slowly progress. He had some nausea from
percocet and was changed to Dilaudid and tolerated that
better and worked with Physical Therapy, and was discharged
to home on postoperative day number ten in stable condition.
His labs on discharge were white blood cell count of 15,600,
hematocrit of 27.8, platelets 787,000. Sodium 136, potassium
4.6, chloride 101, carbon dioxide 27, BUN 16, creatinine 1.2,
blood sugar 111. His INR was 3.5.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. twice a day.
2. KayCiel 20 mEq p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg p.o. q. day.
5. Zantac 150 mg p.o. q. day.
6. Thiamine 100 mg p.o. q. day.
7. Folate 1 p.o. q. day.
8. Multivitamin one p.o. q. day.
9. Coumadin 2 mg and titrate for an INR of 2.0 which will be
followed by Dr. [**Last Name (STitle) 18323**].
DISCHARGE INSTRUCTIONS:
1. The patient will be seen in one to two weeks by Dr.
[**Last Name (STitle) 18323**].
2. The patient will be seen in six weeks by Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 50176**]
MEDQUIST36
D: [**2122-12-4**] 19:07
T: [**2122-12-4**] 20:13
JOB#: [**Job Number 54178**]
ICD9 Codes: 9971, 5990, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4448
} | Medical Text: Admission Date: [**2140-6-16**] Discharge Date: [**2140-6-17**]
Date of Birth: [**2091-4-18**] Sex: M
Service: MEDICINE
Allergies:
Fiorinal / Ketorolac
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
EtOH withdrawal, seizure, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49yo M with long history of EtOH abuse and multiple admissions
to [**Hospital1 18**] for abdominal pain and EtOH admitted with EtOH
withdrawal and abdominal pain. Patient presented to ED
intoxicated last night. CM was called for section 35 because
family has been trying to get him sectioned for several months.
The patient then admitted to SI and was subsequently given a
section 12. A psych consult was placed however he began to
withdraw from EtOH and was unable to comply with psych
evaluation. For withdrawal he was given 5mg po and 5mg IV valium
then 10 and 10 however his HR continued to increase and he felt
jittery. He was given a banana bag and potassium and a head CT
was negative.
His VS prior to transfer to the floor were: HR 113, BP 131/83
20 99%RA, CIWA last 12.
On presentation to the floor patient complained of DTs with
crawling skin and shakiness and requested more valium through
the IV. He also c/o abdominal pain, epigastric, not related to
eating and worse with movement. For this he requested 4 mg IV
dilaudid every 4 hours. He also c/o hungriness. He denied bloody
or black stools. He denied dysuria, frequency, and colored
urine. He denied any recent rashes. He c/o feeling dirty and
wanted a sponge bath.
Past Medical History:
1)Chronic pancreatitis
2)Hepatitis C
3)Sciatica
4)EtOH abuse with h/o DTs and seizures
5)Prostatitis
6)? h/o "aggressive behaviour"
7)frequently leaves AMA
Social History:
Drinks 2-3 1/2 bottles of vodka per day. Smokes when he's
drinking. Has had brief periods of sobriety in the past. Last
drink was morning PTA. Per OMR, psych service and SW service has
h/o opiate seeking behavior with multiple similar admissions.
Psych/sw are in the process of obtaining a section 35 to have
him involuntarily hospitalized for detox.
Family History:
Uncles with EtOH abuse. dad died of "heart aneurysm" in his 60s.
Physical Exam:
VITALS: T 99.4 HR 113 BP 148/72 RR 15 O2 97% on RA
GEN: Disheveled man in NAD
HEENT: NC/AT Sclera anicteric Dry MM
NECK: JVP flat
LUNGS: CTAB
HEART: Tachycardic. Regular. no m/r/g
ABD: soft. TTP epigastric and RLQ without rebound or guarding
EXTREM: dirty. some excoriations on lower legs.
NEURO: a+Ox3 Tremulous. Strength 5/5 bilateral upper and lower
extremities with asterixis r>l
Pertinent Results:
[**2140-6-15**] 03:00PM GLUCOSE-114* UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-23 ANION GAP-18
[**2140-6-15**] 03:00PM ALT(SGPT)-34 AST(SGOT)-43* TOT BILI-0.3
[**2140-6-15**] 03:00PM LIPASE-71*
[**2140-6-15**] 03:00PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.1
[**2140-6-15**] 03:00PM ASA-NEG ETHANOL-375* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-6-15**] 03:00PM WBC-3.4* RBC-4.41* HGB-13.0* HCT-35.7*
MCV-81* MCH-29.5 MCHC-36.4* RDW-16.8*
[**2140-6-15**] 03:00PM NEUTS-53.1 LYMPHS-38.1 MONOS-6.8 EOS-1.6
BASOS-0.4
[**2140-6-15**] 03:00PM PLT COUNT-179
CT Head:
FINDINGS: There is no acute extra- or intra-axial hemorrhage,
large acute territorial infarction, large mass, mass effect or
cerebral edema. There is no shift of normally midline
structures. The ventricles and cortical sulci are slightly
prominent, unchanged, reflecting generalized atrophy (which may
relate to the previous given history of "intoxication"). No
fracture is seen.
There is minimal mucosal thickening in scattered left anterior
ethmoidal air cells.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
#. EtOH Withdrawal and seizure: Multiple admissions for EtOH
withdrawal and seizures.
Patient was admitted to ICU and started on valium per CIWA
scale. He required Q1H CIWA checks and received a total of 25mg
IV Valium. He began requesting more valium despite not
qualifying for it based on the CIWA scale. He then decided to
leave AMA. Psych was called and said that as long as he denied
suicidality he had capacity to leave AMA. He denied vehemently
that he was going to kill himself stating that if he left the
hospital he would drink and might die from that but that he was
not going to actively try to kill himself.
#. Abdominal Pain: Patient has chronic abodminal pain with h/o
hep C and chronic pancreatitis as well as documented
opiate-seeking behavior in the past. He was treated for
pancreatitis with aggressive IVF, NPO, and dilaudid IV. He
requested additional doses of dilaudid despite having a benign
abdominal exam, ability to sit up without pain, and no vital
sign abnormalities consistent with severe pain. He then decided
that he would rather leave the hospital and continue to drink
than stay and receive treatment for his abdominal pain and
withdrawal so as above he left against medical advice.
#. Suicidal Ideation: The patient initially told an ER physician
that if he left he was going to kill himself. This was while he
was still intoxicated. He then refused to talk with the
psychiatrists stating that he meant that if he left he would
continue to drink and that would eventually kill him. He
continued to deny suicidal ideation on the floor and prior to
leaving again denied that he would hurt himself.
#. Communication: with patient and SW [**Doctor First Name 7346**] Epperhart, LICSW
Pager [**Numeric Identifier 22752**]
Medications on Admission:
Seroquel 200mg QHS
Discharge Medications:
Left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
LEFT AMA
Discharge Condition:
LEFT AMA
Discharge Instructions:
LEFT AMA
Followup Instructions:
LEFT AMA
Completed by:[**2140-6-16**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4449
} | Medical Text: Admission Date: [**2147-10-2**] Discharge Date: [**2147-10-6**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81 year-old Spanish
speaking female with a history of hypertension, coronary
angioplasty fifteen years ago who presented to an outside
hospital with malaise, fatigue, nausea, vomiting and
dizziness. The patient reportedly had a V fibrillation
arrest while in the waiting room of the Emergency Department.
The patient was defibrillated multiple times, intubated, with
electrocardiogram showing anterior ST elevation. The patient
was started on aspirin, heparin, Integrilin and Lidocaine
drip and was transferred emergently to the [**Hospital1 346**] for emergent cardiac
catheterization. Upon catheterization the patient was found
to have a 100% occluded left anterior descending artery,
which was stented, an 80% occluded obtuse marginal one, 80%
occluded diagonal one, which was ballooned, a 30% ramus and a
90% right coronary artery, which was not intervened upon.
The patient got a balloon pump for a systolic blood pressure
in the 80s and catheterization values showed an elevated
wedge pressure of 31, PA sat of 42%, cardiac index of 1.58
and a cardiac output of 2.48.
PAST MEDICAL HISTORY: Significant for diverticulitis,
catheterization fifteen years ago in [**Location 8398**]and
esophageal stricture status post balloon dilatation, urinary
retention status post surgery and poorly controlled
hypertension.
SOCIAL HISTORY: Significant for no tobacco use or alcohol
use. The patient lives at home and takes care of her self as
well as her handicapped son.
HOME MEDICATIONS: Lipitor, Lisinopril, Nifedipine and
Protonix.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
97.6. Heart rate normal sinus rhythm at 94. Blood pressures
130s/70s. The patient was ventilated on AC at a tidal volume
of 550 with 12 breaths per minute at 100% FIO2 and a PEEP of
5. In general, the patient was sedated and intubated. HEENT
examination was significant for pin point pupils.
Cardiovascular examination showed a regular rate and rhythm
with a normal S1 and S2 and no murmurs, gallops or rubs were
heard. Lungs were diffusely rhonchi without wheezes.
Abdomen was soft and nondistended. Extremities showed trace
pretibial edema, 2+ femoral pulses bilaterally, 1+ dorsalis
pedis pulses bilaterally and no femoral bruits.
LABORATORY VALUES ON ADMISSION: CPK of 264 with a troponin I
of 3.25. CBC with a white blood cell count of 11.9,
hemoglobin 11.6 and hematocrit of 33.3 and platelets of 403.
Chem 7 showed a sodium of 129, potassium 3.9, chloride of 94
and a bicarb of 25 with a BUN of 23 and a creatinine of 1.0,
glucose 110, calcium 9.3, magnesium 2.0, phosphate 3.1. The
INR was .92, albumin 3.8. The electrocardiogram showed
tachycardia at a rate of 142 with a normal axis and normal
intervals. ST elevations were 3 to 5 mm in V2 through V4 and
there were Q waves in V1 through V3 with ST depressions of 1
mm in the inferior leads. Chest x-ray showed pulmonary edema
in the bilateral upper lungs without effusions. An arterial
blood gas initially showed a pH of 7.28 with a carbon dioxide
of 46 and a PO2 of 71 on 550 tidal volume, 100% FIO2 and a
PEEP of 5.
HOSPITAL COURSE: The patient was transferred to the Coronary
Care Unit in fair condition. She was placed on the usual
post catheterization medications of Plavix and Integrilin as
well as Lipitor, heparin and aspirin. Her balloon pump was
weaned off without complications. Pulmonary wise the patient
had a widened AA gradient and was therefore diuresed with
Lasix. In addition, the patient was felt to have an
aspiration pneumonia and was started on Flagyl and
Levofloxacin with the Flagyl being discontinued after one day
and the Levofloxacin being continued for the course of the
stay in the hospital.
Late during day one on admission the patient went into
complete heart block with ventricular response in the 40s and
a blood pressure drop from 130 systolic to 90 systolic. A
temporary pacer wire was placed urgently into the right
ventricle for pacing of the heart. This occurred without
complications. The patient was intermittently on Dopamine
during this time, but Dopamine was able to be weaned off
shortly after the pacer wire was placed. On day three of
admission the patient was taken back to the cardiac
catheterization laboratory originally for intervention on the
right coronary artery, however, the right coronary artery had
a 50% ostial and a 70% posterior descending artery lesion
that was not treated. However, the left circumflex showed an
80% lesion and was stented. The left anterior descending
artery, which had been stented in the previous
catheterization was still patent and the left main coronary
artery showed a 30% lesion, which was not intervened.
The patient was found to have a decreasing hematocrit on and
off over the course of the hospital stay for which several
units of packed red blood cells were given. The patient was
found to be guaiac positive without any gross bleeding. In
addition, there was concern of bleeding in the pericardium as
well as a retroperitoneal bleed after the second
catheterization on day three of hospitalization. At the time
of this dictation there was no obvious source of bleeding
based on echocardiogram and overall clinical picture.
However, further workup of CAT scan and repeat echocardiogram
will be pursued if deemed necessary.
DISCHARGE DIAGNOSIS:
Large anterior myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern4) 45648**]
MEDQUIST36
D: [**2147-10-6**] 17:28
T: [**2147-10-10**] 07:07
JOB#: [**Job Number **]
ICD9 Codes: 5070, 4271, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4450
} | Medical Text: Admission Date: [**2137-7-14**] Discharge Date: [**2137-7-26**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
generalized body aches
Major Surgical or Invasive Procedure:
Central line
History of Present Illness:
Ms. [**Known lastname 18741**] is a 58 year old female with history of poorly
controlled type 1 diabetes, gastroparesis, CVA, HTN, Hep C, and
multiple prior admissions for DKA presenting with DKA. This time
she presents with abdominal pain consistent with previous
episodes of gastroparesis, as well as just generally feeling
poorly. This all happened when she awoke suddenly and began
[**Known lastname **]. The larger picture of her health is that over the past
several days, she has been feeling "[**Known lastname **] as a dog," with nausea,
[**Known lastname **], diarrhea, eating very little food and taking only some
of her [**Known lastname 31217**].
ED Course
[x] EKG: sinus 104, nonischemic, borderline peaked t's
[x] cxr: nonacute
[x] urine: ketones, no infx
[x] labs with elevated lactate, vbg, lfts, cardiac
- pH-7.16 pCO2-21 pO2-110 HCO3-8
- Lactate:4.8 <-5.5
- WBCs 14.2 - N:89.4 L:8.6 M:1.8 E:0.1 Bas:0.2
R groin line placed for poor access (pt refused IJ)
K on green top 5.5 (d/w bg tech at 0526)
aggressive IVF
[**Known lastname 31217**] IV bolus and gtt
admit to ICU for DKA
On arrival to the MICU, patient's VS. 122/56 HR 105 RR 19 100%
on 2L. She is alert and oriented and complaining of diffuse body
aches that are not new. She denied recent fevers, diarrhea
(endorses constipation), no rashes, no chills, no chest pain, no
changes in vision or hearing in last 3 days, no nuchal rigiditi
endorsed either.
The patient was subsequently stabilized and transitioned to the
hospital medicine service for ongoing management of her blood
glucose levels and development of a plan for transition to home.
Past Medical History:
--Type I DM: diagnosed at age 5, multiple hospitalizations for
DKA and hyperglycemia. Complicated by retinopathy, severe
peripheral neuropathy, and gastroparesis with marked
constipation.
--CVA
--Diabetic polyneuropathy
--Hypertension
--Grave's disease, on MMI
--Seronegative arthritis, followed in rheumatology
--Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
not on antiviral therapy; acquired from a blood transfusion in
[**2110**]. Had previous liver biopsy without significant fibrosis.
Never been treated with antivirals.
--GERD
--Status post bilateral knee arthroscopies
--Migraine headaches
--Asthma
--s/p TAH
--Mouth surgery for removal of tumors
--Bilateral foot drop requiring wheelchair use
Social History:
Patient lives in an apt building, and remains in her wheelchair
on the [**Location (un) 1773**] of the house. She has a son, daughter, and
another brother who live on another floor in the same building.
She has not worked for many years and uses a wheelchair at
baseline.
- Tobacco: never
- Alcohol: denies
- Illicits: denies
Family History:
Mother died of colon cancer. There are multiple family members
with DM.
Physical Exam:
Admission Exam to medical ICU:
General: Alert, oriented, no acute distress
[**Location (un) 4459**]: Sclera anicteric, dry MM, oropharynx clear, EOMI, [**Location (un) 2994**]
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, minimally tender throughout, no rebound or
guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3. CNII-XII intact, 4/5 strength upper extremities,
particularly in bilateral hands with changes consistent with
arthritis. Lower extremities weak and exam limited by patient
effort. gait deferred due to report that patient is wheelchair
bound.
DISCHARGE EXAM:
General: Alert, no acute distress
Abdomen: soft, minimal tenderness, no distension, positive bowel
sounds, no organomegaly appreciated, no rebound or guarding.
Pertinent Results:
[**2137-7-14**] 06:06AM BLOOD WBC-14.2*# RBC-3.62*# Hgb-11.2*#
Hct-36.7# MCV-101* MCH-30.9 MCHC-30.5* RDW-13.5 Plt Ct-412
[**2137-7-14**] 06:06AM BLOOD Neuts-89.4* Lymphs-8.6* Monos-1.8*
Eos-0.1 Baso-0.2
[**2137-7-14**] 04:30AM BLOOD Glucose-745* UreaN-43* Creat-2.1* Na-129*
K-5.6* Cl-85* HCO3-8* AnGap-42*
[**2137-7-14**] 04:30AM BLOOD ALT-23 AST-31 CK(CPK)-71 AlkPhos-96
TotBili-0.3
[**2137-7-14**] 04:30AM BLOOD Lipase-63*
[**2137-7-14**] 04:30AM BLOOD Albumin-3.9 Calcium-8.6 Phos-8.8*# Mg-1.9
[**2137-7-14**] 05:03AM BLOOD Type-[**Last Name (un) **] pO2-98 pCO2-21* pH-7.26*
calTCO2-10* Base XS--15 Comment-GREEN TOP
[**2137-7-14**] 05:03AM BLOOD Lactate-5.5* K-5.5*
[**2137-7-24**] 05:50AM BLOOD WBC-5.9 RBC-3.19* Hgb-9.7* Hct-31.5*
MCV-99* MCH-30.3 MCHC-30.7* RDW-14.5 Plt Ct-367
[**2137-7-24**] 05:50AM BLOOD Glucose-260* UreaN-23* Creat-1.3* Na-132*
K-5.5* Cl-98 HCO3-26 AnGap-14
[**2137-7-21**] 05:35AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7
PA AND LATERAL CHEST RADIOGRAPHS: The cardiomediastinal and
hilar contours
are normal. The lungs are well expanded and clear, without
consolidation,
pleural effusion or pneumothorax. IMPRESSION: No acute
cardiopulmonary pathology.
EKG: Sinus tachycardia. Diffuse non-specific ST segment changes
in the setting of J point elevation with early repolarization in
the anterior precordial leads. Compared to the previous tracing
of [**2137-5-28**], the precordial T waves are slightly less peaked and
the inferior ST-T wave changes are less pronounced. The
ventricular rate is slower.
Brief Hospital Course:
58-year-old female with poorly controlled type I diabetes,
gastroparesis, peripheral neuropathy, CVA, HTN, Hep C, and
multiple prior admissions with DKA presents with DKA in setting
of not taking [**Date Range 31217**] and poor PO intake.
ACTIVE PROBLEMS:
# Diabetic ketoacidosis, uncontrolled, complicated type I
diabetes mellitus, hypoglycemia: She is followed closely by
[**Hospital **] [**Hospital 982**] Clinic. She was initially started on [**Hospital 31217**]
drip and IV fluids. Her anion gap closed and [**Last Name (un) **] was
consulted to help with further titration of SC [**Last Name (un) 31217**]. THere
was no exacerbating factor for DKA other than likely
exacerbation of gastroparesis vs gastroenteritis and missed
[**Last Name (un) 31217**] doses. She was kept in the hospital a number of days for
titration of her [**Last Name (un) 31217**] regimen. Despite the close monitoring
she still had labile blood sugars. She did have multiple
episodes of hypoglycemia as an inpatient. The goal blood sugars
for her regimen are 150-250 given her propensity for
hypoglycemia. She was discharged with very close follow up with
[**Hospital **] [**Hospital 982**] Clinic and her primary care physician. [**Name10 (NameIs) 269**] was
resumed to help her with diabetes management. Social work was
also closely involved with her management to work on social
issues that may be exacerbating her difficult to control blood
sugars. Below is her discharge regimen:
[**Name10 (NameIs) **] SC Fixed Dose Orders
Breakfast Lunch Dinner Bedtime
Glargine 12 Units Glargine 22 Units
[**Name10 (NameIs) **] SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose [**Name10 (NameIs) **] Dose [**Name10 (NameIs) **] Dose [**Name10 (NameIs) **] Dose [**Name10 (NameIs) **] Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-80 mg/dL 8 Units 6 Units 6 Units 0 Units
81-130 mg/dL 10 Units 8 Units 8 Units 0 Units
131-170 mg/dL 12 Units 10 Units 10 Units 0 Units
171-220 mg/dL 14 Units 12 Units 11 Units 0 Units
221-270 mg/dL 18 Units 14 Units 12 Units 2 Units
271-320 mg/dL 20 Units 15 Units 13 Units 4 Units
321-370 mg/dL 22 Units 16 Units 15 Units 6 Units
371-418 mg/dL 24 Units 18 Units 16 Units 8 Units
419-420 mg/dL 26 Units 19 Units 18 Units 10 Units
# Acute kidney injury: Most likely secondary to hypovolemia from
her volume-depleted ketoacidotic state. Her creatinine improved
in the setting of hydration.
# Leukocytosis: She had leukocytosis which resolved without
antibiotic treatment and was likely a stress response. She did
have [**2-23**] blood cultures that grew out corynebacterium species,
which was thought to be a contaminant. Repeat blood cultures
were negative. UA was negative.
# Gastroparesis: No changes were made in her outpatient regimen.
Better glucose control is essential in minimizing symptoms. She
is on metoclopramide, hyoscyamine sulfate and antinausea
medications.
CHRONIC PROBLEMS
# Polyneuropathy with foot drop: Continued on home medications.
# Grave's disease: Continued methimazole.
# Depression: Continued amitriptyline. Patient reports is
controlled, although she feels having her own home would
'improve' her depressed mood.
# Hypercholesterolemia: Continued simvastatin.
# Seronegative arthritis: Continued sulfasalazine.
# Asthma: continue fluticasone-salmeterol 250-50 [**Hospital1 **], with
albuterol PRN.
# Code status: DNR/DNI
Transitional issues:
-follow up with [**Hospital **] [**Hospital 982**] clinic and PCP
Medications on Admission:
per D/C summary on [**2137-6-4**]:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before [**Date Range 16429**] and at bedtime)).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a
day).
7. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
13. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain.
14. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
15. amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
18. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for pain.
19. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for pain.
20. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
22. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
23. [**Hospital1 31217**] sliding scale
Lantus 12 units every morning; 17 units every evening
Humalog: see attached sliding scale
24. sliding scale
humalog
qAM: 81-120 11 U
121-170 12 U
171-220 13U
221-270 14 U
271-320 15U
321-370 17 U
371-420 19 U
421-440 21 U
lunch: 81-120 5 U
121-170 6 U
171-220 7 U
221-270 8 U
271-320 9 U
321-370 10 U
371-420 11 U
421-440 13 U
dinner: 81-120 3 U
121-170 4 U
171-220 5 U
221-270 6 U
271-320 7 U
321-370 9 U
371-420 11 U
421-440 13 U
10pm: 221-270 2 U
271-320 6 U
321-370 7 U
371-420 8 U
421-440 10 U
3am: 221-270 2 U
271-320 6 U
321-370 7 U
371-420 8 U
421-440 10 U
25. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Medications:
1. sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
4. hydrocortisone 1 % Ointment Sig: One (1) Appl Topical DAILY
(Daily) as needed for itching.
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
6. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a
day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before [**Hospital1 16429**] and at bedtime)).
11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO twice a day as needed for pain.
17. amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
18. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
20. Glucagon Emergency 1 mg Kit Sig: One (1) Injection as
needed as needed for hypglycemia: if blood sugar < 50 and not
responsive to juice, glucose tabs, or if unresponsive, give
glucagon injection.
Disp:*1 kit* Refills:*0*
21. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
22. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
23. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
24. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for pain.
25. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
26. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
27. Flovent HFA Inhalation
28. diazepam 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
29. Pen Needle 31 X [**6-5**] Needle Sig: One [**Age over 90 11578**]y (180)
units Miscellaneous 6 times per day.
Disp:*180 units* Refills:*0*
30. [**Age over 90 31217**] lispro 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: please see attached sliding
scale.
Disp:*QS QS* Refills:*2*
31. [**Age over 90 31217**] glargine 100 unit/mL Solution Sig: as directed
Subcutaneous twice a day: 12 units in AM, 22 units in PM.
Disp:*QS QS* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to care for you during your admission. As you
know, you were admitted with diabetic ketoacidosis when you were
not able to eat due to nausea and [**Age over 90 **], and then did not
have your [**Age over 90 31217**]. You required time in the intensive care unit
to feel better. The [**Last Name (un) **] team helped adjust your [**Last Name (un) 31217**] plan,
and encouraged you to eat regular [**Last Name (un) 16429**] throughout the day.
We continued your bowel medicines. It is very important that you
continue these medications at home, including your
metoclopramide with [**Last Name (un) 16429**].
You should make the following changes to your medications on
discharge:
1: Glucagon injection kit: to be used by your nurse or family
member if you are unconcious and your sugars are low
2: [**Last Name (un) **] glargine
3: [**Last Name (un) **] humalog - please see attached sliding scale
You have appointments listed below. Please make sure you arrange
for ambulance or other transporation.
Followup Instructions:
Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 102678**], MD
When: [**Last Name (NamePattern4) 766**] [**7-29**] at 10am
Location: UPHAMS CORNER HEALTH CENTER
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 17630**]
Phone: [**Telephone/Fax (1) 7538**]
*Your appointment may be with another physician as you were
booked as an urgent appointment.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
When: Tuesday [**7-30**] at 8am
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
You will have your visiting nurse restarted when you leave the
hospital.
You should proceed with the following previously [**Telephone/Fax (1) 1988**]
appointment:
Department: RADIOLOGY
When: [**Telephone/Fax (1) **] [**2138-6-2**] at 12:45 PM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4451
} | Medical Text: Admission Date: [**2200-1-30**] Discharge Date: [**2200-2-1**]
Date of Birth: [**2200-1-30**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 65345**], Twin #2, delivered at 35-2/7 weeks
gestation with a birthweight of 2660 grams and was admitted
to the newborn intensive care nursery for management of
prematurity.
Mother is a 31-year-old gravida 6, para 1, 0-4-1, now 3,
woman with estimated date of delivery [**2200-3-3**].
Prenatal screens included blood type B positive, antibody
screen negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, GC and chlamydia negative, and
group B strep positive. The pregnancy is notable for IVF
monochorionic-diamniotic twin gestation, bicornuate uterus,
preterm contractions at 25 weeks that resolved. The mother
presented to [**Hospital3 **] on day of delivery with high blood
pressure and a headache x3 days. The decision was made to
deliver due to concerns for maternal pre-eclampsia. Delivery
was via cesarean section. This infant emerged active,
required stimulation and free-flow oxygen. Apgar scores were
8 at 1 minute and 8 at 5 minutes.
PHYSICAL EXAM ON ADMISSION: Weight 2660 grams (75th
percentile), length 47.5-cm (50-75th percentile), head
circumference 33-cm (75th percentile). Active infant who was
well-appearing in respiratory distress. Palate intact.
Nondysmorphic. Anterior fontanel open, flat, soft. Breath
sounds clear, equal, with easy work of breathing. Heart rate
regular without murmur, normal S1, S2. Abdomen soft,
nontender, nondistended, no hepatosplenomegaly. Spine intact.
Hips stable. Extremities well-perfused, tone appropriate for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Has remained stable
in room air since admission with respiratory rates in the 30s-
50s. No apnea.
CARDIOVASCULAR: Heart rate ranges in the 130s-150s. Recent
blood pressure 72/43 with a mean of 53. Had a soft murmur on
day of life 1 that resolved by day of life 2.
FLUIDS, ELECTROLYTES AND NUTRITION: Was ad lib feedings since
admission with Enfamil 20 or breast milk. At time of transfer
is taking 40-55 mL q. 4 h., is voiding and stooling
appropriately. Discharge weight 2600 grams.
GI: Is due for a bilirubin on [**2200-2-2**].
HEMATOLOGY: Hematocrit on admission 54%.
INFECTIOUS DISEASE: CBC and blood culture were drawn on
admission. There were no sepsis risk factors. There was no
labor, no maternal fever, and membranes ruptured at delivery.
The CBC showed a white count of 9.7 with 27 polys, 0 bands,
platelets 334,000, blood culture has been negative. The
infant did not receive antibiotics.
NEUROLOGY: Exam is age-appropriate.
SENSORY: Hearing screening has not been performed, will need
prior to discharge to home.
CONDITION AT DISCHARGE: Stable preterm infant, feeding well.
DISCHARGE DISPOSITION: Transfer to newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] at [**Hospital **] Health
Center.
CARE AND RECOMMENDATIONS:
1. Feeds: Ad lib with Enfamil 20 or expressed breast milk or
breast feeding.
2. Car seat position screening needs to be done prior to
discharge.
3. State newborn screen to be drawn on [**2200-2-2**].
4. Immunizations: Has not received hepatitis B immunization
yet and will need to be done prior to discharge. Mother
has stated that she will sign consent.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age preterm male infant born
at 35-2/7 weeks gestation.
2. Rule out sepsis without antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2200-2-1**] 18:01:59
T: [**2200-2-1**] 18:24:11
Job#: [**Job Number 65347**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4452
} | Medical Text: Name: [**Known lastname 9756**], [**Known firstname **] Unit No: [**Numeric Identifier 9757**]
Admission Date: [**2159-1-8**] Discharge Date: [**2159-1-10**]
Date of Birth: [**2082-3-18**] Sex: M
Service: CCU
ADDENDUM: This is an addendum to the previous hospital
course from [**2158-12-28**] to [**2159-1-8**] to be dictated by covering
team during those periods of the hospital course.
This is a 79-year-old male with a history of A. Fib., CHF,
status post CABG and AVR, admitted to [**Hospital1 **] for [**Hospital 9758**]
transferred to [**Hospital1 8**] because there was a new flail AV on
echocardiogram. The patient was to have AVR, but had acute
renal failure secondary to dye from his cardiac
catheterization. The patient is now with increased chest
pain that is questionably related to GI causes and has
elevated cardiac enzymes likely to demand ischemia related to
worsening aortic insufficiency. Prior to transfer to the
CCU, it was known that the patient had coronary artery
disease with 70 percent RCA and 70 percent D1. Elevated
enzymes were likely to be demand ischemia in the setting of
worsening AI. The patient was continued on heparin drip, was
taken off of the Nitro drip, as Renal Consult had wanted to
maintain SBP in the 130s to improve flow to the kidneys.
Beta-blocker had been discontinued to limit diastole in the
setting of severe AI. Hydralazine was discontinued and
nesiritide drip was started for afterload reduction. Pain
was controlled with morphine and Protonix. CK was elevated
to 213 with positive MB and troponin. However, they have
trended down, the patient was already on heparin drip. Acute
renal failure was thought secondary to dye from cardiac
catheterization. The patient also has known RAF. The
patient's creatinine peaked at 5.8 and trended down to 4.1
that was variable. He has had good response to Lasix and
Diuril, however, was changed to Lasix drip without good
effect. The patient was returned to his previous regimen of
Lasix and Diuril, continued on Amphojel, Renagel, and Tums
for elevated phosphorous, fluid restricted, and maintained
with a systolic blood pressure over 120. The patient was
felt to be critically ill and was transferred to the Cardiac
Intensive Care Unit for placement of a PA catheter, entailed
CHF therapy as well as working with the Renal Team on
diuresis and removal of patient's fluid. A right IJ was
placed as well as arterial line. The patient had worsening
respiratory failure on transfer to the CCU. ABG 7.33, 40,
101, bicarbonate was 22. Elective intubation was discussed
with patient and his family. The patient was intubated by
Anesthesia. On admission to the CCU, Renal Consult was
obtained and patient was started on CVVH. Swan-Ganz catheter
was also placed as well as an NG tube. The patient was noted
to have a cardiac index of 1.2 and was started on dobutamine.
ABG showed progressive metabolic acidosis with a pH of 7.26,
35, 101, bicarbonate was 16 even after several vent setting
changes. Blood pressure remained low, 95/40. Renal was
called; it was thought that the patient's hemodynamic change
may be secondary to CVVH and the fluid was changed. Renal
was called and decided to change the dialysate on the morning
of [**2159-1-9**]. The patient remained critically ill. On
[**2159-1-9**], the patient was started on Levo, taken off dopa and
started a dig level based on Renal recommendations.
Dobutamine was weaned down and milrinone was added. The
patient had no improvement. His family met with Surgery
Team. It was felt that patient had only 5 percent chance of
survival even with surgery, and he had many complications.
The patient was made DNR/DNI by family members. At 9:00 p.m.
on [**2159-1-9**], the patient went to asystole. Potassium was
3.2. He was given potassium and atropine and heart rate
returned. The patient was continued on CVVH overnight as
well as multiple pressors. The patient continued to do
poorly. Family understood very poor expected outcome and had
multiple meetings with CCU Team and Surgery over the course
of [**2159-1-10**], vancomycin was added for questionable infectious
etiology. On [**2159-1-10**], family decided to wait 24 hours
before addressing the withdrawal of care to give patient the
best chance possible. However, at 3:00 p.m. on [**2159-1-10**], the
patient went into asystole on telemetry. The patient's
family was at his bedside and did not want any further
intervention. The patient was pronounced dead at 2:55 p.m.
in family's presence.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932
Dictated By:[**Last Name (NamePattern1) 1200**]
MEDQUIST36
D: [**2159-5-24**] 13:10:06
T: [**2159-5-24**] 22:23:39
Job#: [**Job Number **]
ICD9 Codes: 4280, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4453
} | Medical Text: Admission Date: [**2147-10-24**] Discharge Date: [**2147-11-5**]
Date of Birth: [**2097-3-5**] Sex: M
Service: EMERGENCY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
anorexia, hypotension
Major Surgical or Invasive Procedure:
paracentesis, central line placement (right internal jugular
vein), arterial line placement, intubation
History of Present Illness:
.
50 yo M with EtOH abuse, liver disfunction and hx of fatty
liver, presented to the ED after several days of n/v,
lightheadedness and syncopal episodes.
.
Pt. reports being in USOH until ~ 2.5 wks ago, when he noted
upon awakening difficulty tolerating PO, nausea and emesis and
subsequent lightheadeness. Sx would improve by late afternoon
when he would be able to take PO. In additino, noted easy
bruising over the past few months (in ED reported last drink
6days ago). He reports drinking 6-10d/night usually, however,
2wks ago, quit given he could not keep anything down. He did not
seek medical attention, but did call PCP's office on [**10-11**] and
reported several fainting episodes. He was advise to come in for
an evaluation but did not do so.
.
Over the past 3 days, his n/v and dizziness became constant. He
could not keep anything down other than clear liquids and had
multiple fainting episodes with falling. ~ 1.5wks ago noticed
his eyes and skin became yellow. Denies confusion or changes in
sleep.
.
He reports having had long standing liver problems, per OSH
records from [**Name (NI) 270**] hospital there is a discussion re:
alcoholic hepatitis and alcohol dependence in [**Month (only) 404**] and
[**2144-12-25**]. [**2145-1-4**] notable for AST 115, ALT 191, total
bili 1.3, direct bili 0.6, total cholesterol 248, HDL 70,
triglycerides 92. CBC with a hemoglobin of 16.0, hematocrit 45,
MCV 107, B12 671, TSH 0.9. Most recent [**Hospital1 18**] labs [**4-2**] notable
for Tbili of 2, negative HepB serologies, negative HIV, HCV, and
transaminitis of AST/ALT 254/106.
.
In the ED ini vs were: T98 P91 BP113/57 R15 O2 97% ra. Initial
BP en route was repoted to be in 80s systolic, but pt. has been
in 110s while in the ED for the rest of the stay. He received
40meQ of IV K in NS 1L, 2g of Mg IV, and 1.5L of NS. Underwent
Liver US (see below) but did not have a location of ascites that
could be tapped safely. Had guiac positive yellow stool.
.
On the floor, VS 98.4 100/72 104 16 95% RA. Pt. did not feel
lightheaded and had no complaints.
.
Review of systems:
(+) Per HPI, abdominal bloating.
Denied hemoptysis, melena, bloody BMs, or abdominal pain. No
fevers but had chills, night sweats.
.
Signif weight loss. Otherwise negative in detail.
Past Medical History:
EtOH Abuse
Fatty liver
HTN
Urethritis
Allergic rhinitis
Gout
Social History:
The patient is an IT manager for [**Company 25186**]. Lately, he has
been working seven days a week and many nights as well. He has
been on his current job for approximately three and a half years
and he is looking for other work because of the level of stress.
There is also a great deal of concern about people losing their
jobs. He is divorced, has one child, and has been divorced for
approximately a year. No tobacco. [**Doctor First Name **] currently drinks on
average six drinks nightly after work and at times more.
Recently on his golfing trip he was drinking up to 12 drinks per
day. He used to drink mostly beer, but lately his drink of
choice is vodka tonic. He notes that his work is extremely
stressful and this is his way for relaxing and coping with his
work. He notes that he has had an alcohol use problem for some
time and at times in the past and has been able to decrease his
alcohol consumption to one or zero drinks. He has attended AA
meetings in the past, but generally "falls off the wagon". He
gets tired of going and talking about alcohol all the time. He
has previously used other strategies to deal with stress,
including walking. All of his friends currently also drink
alcohol and he notes that they have been drinking more recently
as well also. No drug use. Exercise: He used to work at a gym,
but has not been exercising recently due to his schedule. Diet:
The patient states his diet and has not been good lately. There
was a period a couple of months back when he noticed that he was
recently not eating anything at all and he began to feel lousy.
Within the last month, he has made a concerted effort to try to
eat three meals a day.
Family History:
Paternal grandfather died of lung cancer.
Maternal grandfather also died of cancer, had emphysema. Bother
grandfathers were alcoholics.
Maternal and paternal grandmothers lived into their 90s. His
parents are both alive at 73 and in good health except for his
father has some eye problems.
[**Name (NI) **] family history of liver disease or autoimmune disease.
Physical Exam:
Vitals: 98.4 100/72 104 16 95% RA.
General: Alert, oriented, no acute distress, but ill appearing.
HEENT: Icteric sclera, dMM, oropharynx clear.
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate, normal S1 + S2, hyperdynamic
Abdomen: soft, distended, + fluid wave, NT, bowel sounds
present, no rebound tenderness or guarding, hard liver, no
splenomegaly
Ext: Warm, well perfused, atrophic, 2+ pulses, no edema
MSK: Bruising on his back, spider angiomas.
Neuro: MOYb intact, no asterixis, some tremor, no piloerection.
Pertinent Results:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 104241**] M 50 [**2097-3-5**]
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study
Date of [**2147-10-24**] 8:08 PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2147-10-24**] 8:08 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip #
[**Clip Number (Radiology) 104242**]
Reason: eval for portal venous thrombosis
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with liver failure
REASON FOR THIS EXAMINATION:
eval for portal venous thrombosis
Wet Read: NATg TUE [**2147-10-24**] 9:50 PM
Echogenic liver with GB wall thickening stones/polyps. Normal
CBD, GB wall
thickening likely related to hepatitis . Normal arterial, portal
and hepatic
venous waveforms throughout with recanalization of the umbilical
artery.
Ascites.
Final Report
CLINICAL INFORMATION: 50-year-old male with liver failure.
TECHNIQUE AND FINDINGS: Grayscale and color Doppler son[**Name (NI) 493**]
images were
obtained of the right upper quadrant, demonstrating an echogenic
liver. There
is gallbladder wall thickening, but the gallbladder does not
appear distended.
Small, subcentimeter, gallbladder polyps are again seen without
significant
change. Two small, subcentimeter rouneded structures in the
gallbadder,
similar in appearance to polyps, but demonstrating shadowing,
may be due to
stones. The common bile duct is normal in caliber. There is no
definite
intrahepatic biliary ductal dilatation. There is normal
hepatopetal portal
venous flow and arterial flow. The hepatic veins are patent and
demonstrate
normal direction of flow. There is recanalization seen of the
umbilical vein.
Ascites is present. The spleen is enlarged, measuring 14.6 cm in
length. The
pancreas is not well seen due to overlying bowel gas.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease including fibrosis/cirrhosis cannot be excluded on this
study.
2. Gallbladder wall thickening, polyps, and possible stones,
though the common
bile duct is normal in caliber and the gallbladder is not
distended, with a
convex contour seen anteriorly. These findings are more likely
related to
hepatitis and not acute cholecystitis.
2. Patent hepatic vasculature.
3. Ascites, recanalization of the umbilical vein, and
splenomegaly suggest
portal hypertension.
[**2147-10-26**] 02:36PM BLOOD Glucose-116* Lactate-4.8* Na-126* K-3.6
Cl-102
[**2147-10-24**] 07:50PM BLOOD ALT-57* AST-326* LD(LDH)-237 CK(CPK)-49
AlkPhos-165* TotBili-29.8* DirBili-19.8* IndBili-10.0
[**2147-11-4**] 02:35AM BLOOD TotBili-31.0*
[**2147-11-4**] 02:35AM BLOOD WBC-21.2* RBC-2.45* Hgb-10.1* Hct-29.0*
MCV-119* MCH-41.1* MCHC-34.7 RDW-21.9* Plt Ct-102*
[**2147-10-26**] 2:37 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2147-10-29**]**
Blood Culture, Routine (Final [**2147-10-29**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2147-10-27**]):
REPORTED BY PHONE TO DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PAGER# [**Serial Number 104243**] @ 0627
ON
[**2147-10-27**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2147-10-27**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
50 yo M with EtOH abuse, liver disfunction and hx of fatty liver
(and now cirrhosis) presented to the ED after several days of
n/v, lightheadedness and syncopal episodes with massive
hyperbilirubinemia and synthetic dysfunction.
.
# Alcoholic hepatitis: On admission, MELD of 28, discriminant fx
of 70. Pt did not have any evidence of infection on admission
(ascitic fluid negative for SBP) and portal vein blood flow
appeared normal. On the floor the pt was started on
pentoxyfilline. On [**10-25**] the pt had an IR-guided paracentesis
that he tolerated well and 580cc was removed.
# ICU Course, MSSA Bacteremia, Hypoxia, Liver failure: On [**10-26**]
the pt was noted to be acutely confused, with HR in 140's, RR
40's, temp 98.1. Pt acknowledged that he had last had a drink on
[**10-22**] or [**10-23**]. Pt was given ativan IV and transferred to the
ICU for further rx of presumed alcohol withdrawal. On [**2147-10-27**] pt
was intubated due to high requirement for benzodiazepines and
worsening evidence of sepsis. The pt was noted to have positive
blood cultures and was started on Vanc/Zosyn and TTE did not
show evidence of vegetation. Pt was also started on pressors. On
[**10-27**] radiology was unable to perform US guided paracentesisi d/t
too little fluid. On [**10-28**] the pt was started on tubee feeds and
blood cultures grew MSSA and the pt was started on Nafcillin 2g
q4. CT abdomen that day also showed enterocolitis. On [**10-29**] it
was felt that pt had an ileus, so TF were stopped. On [**11-1**] TEE
was negative for endocarditis. On [**11-2**] bronchoscopy was
performed given worsening secretions from NG tube. No obvius
pneumonia identified - started vancomycin. Due to continueing
volume overload, and minimal urine output with 20mg/hr lasix
drip, Metolazone was added. On [**11-3**] a family meeting was held
to discuss the pt's very poor prognosis. The family did not want
to "pull the plug," as other members of their family have gone
on to lead productive lives after doctors have told [**Name5 (PTitle) **] that
they would soon die. Overnight [**Date range (1) 101286**] the pt required
increasing amounts of pressors due to plummeting blood
pressures. The pt also became more difficult to oxygenate. On
[**11-4**] a family meeting was held again and the decision was made
to not escalate care. On [**11-5**] the patient's family asked to
change goals of care to be more comfort-oriented. The patient
was continued on sedation and the patient soon expired.
Medications on Admission:
ALLOPURINOL - 100 mg daily
INDOMETHACIN - 50 mg three times a day as needed for gout flares
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
ICD9 Codes: 5849, 2761, 5119, 5180, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4454
} | Medical Text: Admission Date: [**2112-3-11**] Discharge Date: [**2112-3-18**]
Date of Birth: [**2029-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain radiating to midback and jaw
Major Surgical or Invasive Procedure:
[**2112-3-14**] Coronary artery bypass graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
right coronary artery, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal)
History of Present Illness:
This 83 year old female developed substernal pressure radiating
to her back, neck and jaw. She called EMS and the chest pressure
subsided on its own in 15 minutes prior to EMS arrival. She
relates several years of dyspnea on exertion. She was brought to
[**Hospital6 33**] were she was admitted and a cardiac
catheterization was done. She was found to have multivessel
disease and is was transferred to [**Hospital1 18**] for revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Non insulin dependent diabetes
Osteoarthritis
Shingles [**2111**]
Cholecystectomy
bilateral hip replacement
resection of thyroid nodule and a right parotid excision
Social History:
Race:Caucasian
Last Dental Exam:partial on lower and full upper dentures
Lives with:Son, very active does her own ADLs and walks her dog
3
times/day. Does not use any assisted devices.
Contact:[**Name (NI) **] (son) [**Telephone/Fax (1) 10811**], [**Doctor First Name **] (daughter) [**Telephone/Fax (1) 10812**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, history
of
40 ppy
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-23**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father died of MI at age 51,
Two brothers died in their 50's of uncertain causes
Physical Exam:
Pulse:83 Resp:18 O2 sat:95/RA
B/P 117/78
Height:5' Weight:89.3 kgs
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-occas irreg] Irregular [] Murmur [] grade ______
Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema [x] none
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 None Right: Left:
Pertinent Results:
[**2112-3-12**] Echo: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. 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) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
.
[**2112-3-16**] 04:35AM BLOOD WBC-17.9* RBC-3.14* Hgb-9.8* Hct-28.0*
MCV-89 MCH-31.1 MCHC-34.8 RDW-14.1 Plt Ct-235
[**2112-3-11**] 07:15PM BLOOD WBC-14.0* RBC-4.17* Hgb-13.5 Hct-37.9
MCV-91 MCH-32.3* MCHC-35.5*# RDW-13.8 Plt Ct-363
[**2112-3-11**] 07:15PM BLOOD Glucose-111* UreaN-30* Creat-0.9 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-14
[**2112-3-11**] 07:15PM BLOOD %HbA1c-6.1* eAG-128*
[**2112-3-18**] 12:37AM BLOOD WBC-14.9* RBC-3.04* Hgb-9.3* Hct-27.8*
MCV-92 MCH-30.7 MCHC-33.6 RDW-13.5 Plt Ct-347
[**2112-3-18**] 12:37AM BLOOD PT-11.6 INR(PT)-1.1
[**2112-3-18**] 12:37AM BLOOD Glucose-135* UreaN-35* Na-136 K-4.9
Cl-101 HCO3-27 AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname **] was transferred from outside hospital after
cardiac cath revealed severe three vessel coronary disease
requiring surgery. Upon admission she was medically managed and
underwent surgical work-up. On [**3-14**] she underwent coronary
artery bypass graft x 4. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition.
Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. Post-op day one she was
started on beta-blockers and diuretics and gently diuresed
towards her pre-op weight. Later on this day she was transferred
to the step-down floor for further care. Chest tubes and
epicardial pacing wires were removed per protocol.
Physical Therapy worked with her for mobility and strength. She
was able to return to her home where she lives with her son who
will be with her for the first week.
On [**2-/2029**] she developed rapid atrial fibrillation with a
ventricular response of 140 and transient BP to 80s. She
received a total of 10mg of IV Lopressor with restoration of
sinus rhythm. The following day she had multiple short bursts
of SVT and Amiodarone and Coumadin were instituted. She was in
sinus with occassional VPCs/ junctional beats at discharge. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], her primary care physician agreed to monitor her
anticoagulation. She will take 2.5 mg of Coumadin on [**3-18**]-4 and
have an INR drawn on [**3-21**].
All follow up appointments were given.
Medications on Admission:
Zocor 40mg HS
Zestril 30mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
Janusian 10mg Daily
Hydrochlorothiazide 25mg Daily
Aspirin 81mg Daily
Lopressor 12.5mg [**Hospital1 **] (started at [**Hospital3 **])
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg (2 tablets) twice daily for two weeks, then
200mg (one tablet) twice daily for two weeks, then 200mg (one
tablet) daily until directed to discontinue.
Disp:*100 Tablet(s)* Refills:*2*
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
12. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: one tablet at 4pm on [**3-18**]. Then as directed by Dr.
[**Last Name (STitle) **] on [**3-21**].
Disp:*100 Tablet(s)* Refills:*2*
14. Outpatient [**Name (NI) **] Work
PT/INR on [**2112-3-21**], then prn.
Please call result to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at
[**Telephone/Fax (1) 10813**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 4
Hypertension
Hyperlipidemia
Non insulin dependent diabetes
Osteoarthritis
Shingles [**2111**]
s/p Cholecystectomy
s/p bilateral hip replacement
s/p resection of thyroid nodule and right parotid excision
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg left - healing well, no erythema or drainage.
Edema: 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**2112-4-13**] at 1:30pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] ([**Hospital Ward Name 23**] 7) on [**2112-3-30**] at 10am
Please call to schedule appointments with:
Primary Care Dr. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 10813**]in [**4-21**] 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 paroxysmal atrial
fibrillation
Goal INR 2-2.5
First draw [**2112-3-21**]
Results to phone: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10813**]
Completed by:[**2112-3-18**]
ICD9 Codes: 4111, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4455
} | Medical Text: Admission Date: [**2161-9-25**] Discharge Date: [**2161-10-5**]
Date of Birth: [**2106-1-16**] Sex: M
Service: COLORECTAL
ADMITTING DIAGNOSIS:
1. End-stage renal disease.
2. Adult respiratory distress syndrome.
3. Severe colitis.
4. Fatal arrhythmia.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with end-stage renal disease secondary to
post-Streptococcal glomerular nephritis and CPDD, and adrenal
insufficiency, who presented with two to three weeks of lower
abdominal pain and was found to be Clostridium difficile
positive. Upon work-up the patient showed worsening
abdominal CT scan consistent with pan-colitis.
The patient was initially treated with Vancomycin
intravenously with p.o. Ciprofloxacin and Flagyl. On
[**2161-9-28**], the patient was found to be gasping for air while
on 100% non-rebreather mask with an arterial blood gases of
7.04, 80, 43. The patient was immediately intubated and
admitted to the Surgical Intensive Care Unit at which time
the patient was found to have atrial fibrillation with heart
rate between 100 to 140. Rate was very difficult to control
and Diltiazem drip was initiated.
On [**2161-9-27**], the patient's heart rate remained
between 90 to 110 with Diltiazem drip at 10 mg per hour and
blood pressure was also difficult to maintain. The patient
responded well initially to boluses with decrease in
tachycardia, however, due to the worsening pan-colitis, the
patient was taken back to the Operating Room for a subtotal
colectomy.
PHYSICAL EXAMINATION: N/A.
SUMMARY OF HOSPITAL COURSE: The patient is a 55 year old
male status post subtotal colectomy and end-ileostomy for
infarcted small intestine and colitis with pseudomembranes.
The patient was initiated on broad-spectrum antibiotics with
cultures sent. The patient's CT scan of the abdomen
indicated a diffuse thickening of terminal ileum and large
intestine to the transverse colon without stranding.
A repeat CT scan immediately prior to the subtotal colectomy
indicated pan-colitis which progressed from prior scan but no
evidence of perforation.
Immediately postoperatively, the patient continued to have
respiratory distress requiring increased pressor support and
required continued transfusion with seven units both of P,
two units of packed red blood cells and four liters of
Crystalloid.
Despite the continued resuscitation, the patient remained
hypotensive with continued lactic acidosis requiring
bicarbonate replacement. The aggressive resuscitation
continued until [**2161-10-5**], when after a long
discussion with the family members, the patient was made
comfort measures only.
The patient developed a ventricular fibrillation shortly
thereafter and expired later on that evening.
DISCHARGE DIAGNOSES: Status post subtotal colectomy and
ileostomy.
DISPOSITION: Death.
[**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**]
Dictated By:[**Name8 (MD) 6247**]
MEDQUIST36
D: [**2162-2-28**] 12:11
T: [**2162-2-28**] 16:26
JOB#: [**Job Number 6248**]
ICD9 Codes: 5185, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4456
} | Medical Text: Admission Date: [**2164-3-16**] Discharge Date: [**2164-3-18**]
Date of Birth: Sex:
Service: MEDICAL INTENSIVE CARE UNIT [**Location (un) **] SERVICE
REASON FOR ADMISSION: Fevers and chills with decreased urine
output.
HISTORY OF PRESENT ILLNESS: This is an 88 year old, nursing
home resident, with a history of recurrent Clostridium
difficile colitis, urinary retention with an indwelling
Foley, history of hypotension, who presents with two days of
fevers, rigors, hypotension and decreased urine output, over
one to two days prior to admission. The patient was noted to
have decreased urinary output and hematuria at the nursing
home. The Foley catheter was changed at the nursing home but
did not result in increased urine output. The patient was
also noted to have a cough productive of a large amount of
brown sputum. He also reported one day of fevers, chills and
some mild nausea with one episode of vomiting two days prior
to admission. Of note, he also noted profound dysuria,
despite changing the Foley catheter. The patient was
transferred to [**Hospital1 69**] where
vital signs demonstrated a temperature of 103.2; heart rate
in the 160's; blood pressure of 70/40. The sepsis protocol
was initiated. He initially received Vancomycin, Ceftazidime
and Flagyl. He was given a total of 7 liters of normal
saline. A right internal jugular sepsis catheter was placed
and the patient was transferred to the Medical Intensive Care
Unit for sepsis protocol monitoring. Of note, he denied
abdominal pain, light headedness, diarrhea, bright red blood
per rectum, chest pressure, shortness of breath, cough,
peripheral edema or palpitations.
PAST MEDICAL HISTORY:
1. The patient received most of his medical care at [**University/College 18328**]Medical Center and, in [**2163-10-12**], was
hospitalized in their Intensive Care Unit with an episode of
sepsis, secondary to a gangrenous cholecystitis with
accompanying pancreatitis. At that time, he underwent an
open cholecystectomy with a liver biopsy and was transferred
to the Surgical Intensive Care Unit for monitoring. He also
had a biliary stent placed for residual drainage of infected
fluid collection. This was performed via endoscopic
retrograde cholangiopancreatography.
2. He also has had multiple episodes of Clostridium
difficile colitis.
3. [**Last Name (un) 3671**]-[**Doctor Last Name **] macroglobulinemia.
4. History of benign prostatic hypertrophy with chronic
indwelling Foley catheter, which is changed once per month,
at the discretion of his outpatient urologist at [**Hospital1 2177**].
5. Glucose intolerance.
6. Tachyarrhythmia, not otherwise specified, with known
history of paroxysmal atrial fibrillation, not on Coumadin.
7. Hypotension, with a systolic blood pressure at baseline
in the 90's.
8. Major depressive disorder.
9. History of splenectomy, status post trauma in [**2155**].
10. History of upper gastrointestinal bleed, not otherwise
specified.
MEDICATIONS ON ADMISSION:
1. ProMod 2 q. day.
2. Celexa 30 mg q. day.
3. ASA 81 q. day.
4. Vitamin B-12 1 mg q. day.
5. Multi-vitamin one q. day.
6. Flomax 0.4 q. day.
7. Megace 400 mg q. day.
8. KCl 40 mg q. day.
9. Protonix 40 mg q. day.
10. Advair one puff twice a day.
11. Cholestyramine 2 grams twice a day.
12. Os-Cal one twice a day.
13. Neutra-Phos one three times a day.
14. Remeron 7.5 q h.s.
15. Tylenol prn.
16. Proscar 5 mg q. day.
SOCIAL HISTORY: 35 pack year tobacco history. Quit five
years ago. History of alcohol abuse. Has been sober for the
past five years. No history of drug use. He lives at the
[**Hospital3 2558**].
PHYSICAL EXAMINATION: Temperature 101.7; heart rate 133;
blood pressure 95/55; respiratory rate 20; breathing 95% on
100% non rebreather face mask. General: Frail appearing,
labored breathing. Positive use of accessory muscles. HEAD,
EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Dry mucous membranes. No lymphadenopathy. Neck
supple. Chest: Minimal crackles at the bases bilaterally.
Cardiovascular: Tachycardia, regular rhythm, no murmurs.
Abdomen: Positive bowel sounds, firm in the suprapubic
region but nontender. No organomegaly. Guaiac positive brown
stool. Extremities: No edema. Dermatology: No rashes. The
patient was sitting in a large pile of stool.
LABORATORY DATA: White blood cell count of 17.7 with 76%
neutrophils, 22% bands and 2% lymphocytes. Hematocrit of 37.
Platelets 48. Chemistry 7: 138, 4.7, 108, 13, 62, 2.7, 156.
Lactate of 5.7. ALT 8. AST 14. Amylase 58. Alkaline
phosphatase 205. Total bilirubin 0.3. Albumin 2.9. CK 40.
INR of 1.1. Troponin of 0.04. Initial arterial blood gas:
7.33, PC02 of 22, P02 of 89.
Electrocardiogram showed sinus tachycardia at 147 with a
normal axis; no ST or T wave changes; normal intervals. No
prior available for comparison.
Urinalysis showed large blood; greater than 50 red cells;
greater than 50 white cells; many bacteria; less than 1
epithelial cell; negative nitrite; moderate leukoesterase.
Chest x-ray significant for a left lower lobe infiltrate.
HOSPITAL COURSE: 1. Sepsis. The patient was initiated on
the sepsis protocol and was placed on Vancomycin, Ceftazidime
and Flagyl for empiric coverage of most likely urosepsis with
the Ceftazidime, especially given the patient's asplenic
status and susceptibility to encapsulated organisms. He was
also placed on Flagyl for a question of Clostridium difficile
colitis given his history. Xigris was considered; however, it
was not instituted, given the patient's history of
gastrointestinal bleed. He was started on Levophed for blood
pressure support. He was bolused with normal saline as
needed. A cortisol stimulation test was performed and showed
no evidence of hypoadrenal state. The patient was eventually
weaned off of Levophed on [**2164-3-17**].
2. Respiratory failure. The patient had an underlying
metabolic gap acidosis, secondary to lactic acid production.
He had an appropriate compensatory respiratory alkalosis;
however, he was unable to breathe down his C02 and required
intubation on [**2164-3-17**], secondary to labored breathing and
acute hypoxemia. This was thought to be most likely
secondary to volume overload, status post aggressive fluid
resuscitation. The patient was quickly weaned off of the
ventilator on [**2164-3-17**]. The patient was transferred to the
medical team on [**2164-3-18**] and was oxygenating well on nasal
cannula.
3. Genitourinary: On [**2164-3-16**], the patient was noted to have
a markedly distended bladder. A bladder ultrasound was
performed at the bedside, which demonstrated approximately
one liter of fluid in the urinary bladder. The urology
consult was obtained and after replacing the patient's Foley
catheter, 900 cc of dark red urine was drained from the
urinary bladder. He was maintained on Proscar and Flomax per
his outpatient regimen. It was recommended that he follow-up
with his urologist for urodynamic study and possible
transurethral resection of prostate.
4. Gastrointestinal bleed: Given his guaiac positive stool,
he was continued on Protonix. Stools were guaiac negative
subsequent to the initial stool on admission.
5. Diarrhea: The patient was tested negative for
Clostridium difficile colitis times three.
6. Glucose control: He was maintained euglycemic on insulin
sliding scale.
7. Acute renal failure: The patient initially had a
creatinine greater than 2. This was felt to be secondary to
post obstructive nephropathy and his creatinine decreased to
1.5 status post drainage of the urinary bladder. The patient
was transferred to the medical floor team on [**2164-3-18**]. Given
the fact that he was extubated off of pressors, maintaining
adequate oxygenation on nasal cannula and maintaining
adequate blood pressure without the need for frequent
bolusing. A discharge addendum will be dictated separately.
8. Infectious disease: Of note, the patient grew out
Klebsiella, pansensitive from his urine on [**2164-3-16**]. He grew
out 4 out of 4 bottles of gram negative rods, with Klebsiella
and Enterococcus on [**3-15**] from his blood cultures. He was
negative for Clostridium difficile times three. Please note
that his antibiotic coverage was changed to Levofloxacin and
p.o. Vancomycin for targeted treatment for gram negative rods
as well as Clostridium difficile prophylaxis.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AIY
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2164-3-18**] 11:28
T: [**2164-3-19**] 04:39
JOB#: [**Job Number 102631**]
ICD9 Codes: 5849, 5990, 2765, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4457
} | Medical Text: Admission Date: [**2127-9-28**] Discharge Date: [**2127-10-6**]
Date of Birth: [**2127-9-28**] Sex: M
THIS IS AN INTERIM/TRANSFER SUMMARY FOR THE PERIOD TO [**2127-10-6**]
Service: NEONATOLOGY
HISTORY: [**Known lastname 449**] [**Known lastname **] was born at 26-6/7 weeks gestation by
cesarean section to a 39-year-old gravida 2, para 1 now 2
woman. He is being transferred today to [**Hospital3 1810**]
for ligation of his patent ductus arteriosus. The mother's
prenatal screens are blood type A positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
antigen negative, and group B Strep unknown.
This pregnancy is remarkable for cervical incompetence
leading to cerclage placement at 12 weeks. The mother was
admitted on [**2127-9-11**] for preterm labor and treated with
nifedipine tocolysis and bed rest, and received a course of
betamethasone at that time. She had refractory preterm labor
thus leading to delivery.
This infant emerged with good tone and cry and delivered
spontaneously, whose Apgars were seven at one minute and
eight at five minutes.
His birth weight was 1070 grams (50-75th percentile). His
birth length was 37 cm (50th-75th percentile), and his head
circumference was 26.5 cm (50th-75th percentile).
The infant's physical exam reveals an extremely preterm
infant. Anterior fontanel is soft and flat, nondysmorphic,
intact palate. Chest with moderate retractions with
spontaneous breaths, fair breath sounds bilaterally with few
scattered coarse crackles. Heart was regular, rate, and
rhythm, no murmur. Pink and well perfused. Abdomen is soft
and nondistended with three vessel umbilical cord, patent
anus, normal preterm male genitalia with testes undescended
bilaterally, age appropriate tone and reflexes, bruising of
arms bilaterally and normal spine, limbs, hips, and
clavicles.
HOSPITAL COURSE BY SYSTEMS: [**Known lastname 449**] received three doses of
surfactant. He has remained on SIMV with his current
settings of a peak inspiratory pressure of 18. Peak end
expiratory pressure of 5. A breath rate of 26 requiring room
air to 30% O2, but his capillary blood gas on [**10-6**] was pH
7.26, CO2 of 62, at that time his breath rate was increased
from 24 to 26. On exam, he had some mild subcostal
retractions. Breath sounds are clear and equal.
Cardiovascular status: He has received two courses of
indomethacin first on day of life #2 for a PDA documented by
echocardiogram, and then again on [**10-2**] again after a PDA was
documented by echocardiogram. A follow-up echocardiogram on
[**10-4**] revealed that there was still moderate size PDA
present, and decision was made to proceed for ligation. He
did require some dopamine for blood pressure support
soon after admission until day of life four. Since that
time, he has remained normotensive. He has had some
metabolic acidosis requiring some doses of sodium bicarbonate
the last time on [**2127-10-5**].
On exam, he has a grade 1-2/6 systolic ejection murmur at the
left sternal border.
Fluids, electrolytes, and nutrition status: At the time of
transfer, his weight is 1,020 grams. His length is 36.5 cm
and his head circumference is 26.25 cm. He has never had any
enteral feeds. He is currently on parenteral nutrition and
interlipids at 110 cc/kg/day currently going through an
umbilical venous catheter. His dextrose is 17% with his
blood glucoses ranging from 125 to 135, however, it was 250
on the morning of transfer. His protein is 3.5 g/kg/day.
His fat is 3 g/kg/day, and he is getting 20 mEq/L of sodium,
and 20 mEq of potassium/L, and 30 mEq of calcium/L.
His last electrolytes on [**2127-10-6**] were sodium 128, potassium
4.9, chloride 95, bicarbonate 27. His electrolytes on
[**2127-10-5**] were sodium 140, potassium 3.8, chloride 104,
bicarbonate 26, BUN 33, creatinine 0.6. Further laboratories
done on [**10-2**] were calcium 9.3, phosphorus 4.8, magnesium
3.7, and triglycerides 83. His urine output is approximately
2-3 cc/kg/hour.
Gastrointestinal status: He has been treated with
phototherapy for hyperbilirubinemia of prematurity from day
of life one until day of life #7. His peak bilirubin
occurred on day of life #3 with total of 5.7, direct 0.5.
His bilirubin on the day of transfer was total 4.1, direct
1.2, indirect 2.9, and that value will be repeated prior to
transfer. Bilirubin level before discontinuing phototherapy
on [**10-5**] was total 2.9, direct 0.4.
Hematological status: He has received two blood transfusions
of packed red blood cells, the last on [**2127-10-2**]. His
hematocrit on day of transfer is 30.
Infectious disease status: [**Known lastname 449**] was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. Blood cultures remained negative. Cerebrospinal
fluid was negative with a white blood cell count of 3 on
[**2127-10-2**]. The plan was to complete seven days of
antibiotics, and those were discontinued on [**2127-10-5**].
Neurological status: A head ultrasound on [**2127-9-30**] was
within normal limits. A head ultrasound will be repeated on
[**2127-10-6**].
The infant is transferred in good condition.
The infant is being transferred to [**Hospital3 1810**] for
surgery for ligation of a patent ductus arteriosus.
Primary pediatric care provider has not yet been identified.
The infant is discharged on no medications.
INTERIM DISCHARGE DIAGNOSES:
1. Status post prematurity 26-6/7 weeks gestation.
2. Status post respiratory distress syndrome.
3. Status post presumed sepsis.
4. Status post hyperbilirubinemia of prematurity.
5. Patent ductus arteriosus.
REVIEWED BY: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2127-10-6**] 06:04
T: [**2127-10-6**] 06:02
JOB#: [**Job Number 50845**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4458
} | Medical Text: Admission Date: [**2139-9-13**] Discharge Date: [**2139-9-14**]
Date of Birth: [**2056-6-1**] Sex: F
Service: NEUROLOGY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
transfer from OSH for large brain hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old female with h/o mild Alzheimer's disease,
L CEA in 05, HTN, elevated lipids, bladder CA (no known
metastasis),
who presents as a transfer from OSH with unresponsiveness, L
blown pupil and a very large intra cranial hemorrhage on CT.
Daughter reports that she was last seen well yesterday. This
morning she spoke to her over the phone and she sounded weird.
She replied "OK doc", she was speaking slowing and then stopped
talking. She went to her house and found her on the floor in the
kitchen, snoring. She was taken to OSH where she was found to
have a dilated left pupil, she was intubated and a CT head
showed
a devastating hemorrhage affecting almost all right hemisphere
with significant shift. She was transferred here for evaluation
by neurosurgery who found it an extremely poor surgical
candidate. The family opted to make her CMO.
Past Medical History:
mild Alzheimer's disease,
L CEA in 05
HTN,
elev lipids,
bladder CA (no known metastasis),
Social History:
Patient recently lost husband and lives alone with
help from family. Long past smoking history, occ alcohol use,
no
drugs
Family History:
NC
Physical Exam:
:99.1 intial BP:240/92 -> 180/85 HR:59 On Mechanical
Ventilation R:15 O2Sats 100% on vent
Gen: Intubated elderly lady, non-responsive.
Neck: In cervical collar
Lungs: Mechanical breath sounds b/l, present on both sides
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neurologic examination:
Mental status: intubated, unresponsive to noxious stimuli with
some decrebrating posturing
Cranial Nerves:
Pupils unreactive; R 2mm and L 4mm, no corneal, normal Doll's
face appears symmetric, tongue midline
Motor: No movement to noxious stimuli, some decerebrating
posturing. Increased tonus throughout
Sensation: No retraction to noxious stimuli
Refl: upgoing toes
Coordination and GAit: Unable to examine
Pertinent Results:
[**2139-9-13**] 01:19PM URINE HOURS-RANDOM
[**2139-9-13**] 01:19PM URINE GR HOLD-HOLD
[**2139-9-13**] 01:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2139-9-13**] 01:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-9-13**] 01:19PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2139-9-13**] 01:19PM URINE HYALINE-0-2
[**2139-9-13**] 01:19PM URINE AMORPH-FEW
[**2139-9-13**] 12:50PM PH-7.40 COMMENTS-GREEN TOP
[**2139-9-13**] 12:50PM GLUCOSE-214* LACTATE-1.8 NA+-142 K+-4.4
CL--107 TCO2-21
[**2139-9-13**] 12:50PM HGB-13.1 calcHCT-39 O2 SAT-99
[**2139-9-13**] 12:50PM freeCa-1.12
[**2139-9-13**] 12:35PM UREA N-49* CREAT-1.6*
[**2139-9-13**] 12:35PM estGFR-Using this
[**2139-9-13**] 12:35PM LIPASE-35
[**2139-9-13**] 12:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-9-13**] 12:35PM URINE HOURS-RANDOM
[**2139-9-13**] 12:35PM URINE HOURS-RANDOM
[**2139-9-13**] 12:35PM URINE GR HOLD-HOLD
[**2139-9-13**] 12:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-9-13**] 12:35PM WBC-16.2* RBC-3.74* HGB-11.7* HCT-35.7*
MCV-95 MCH-31.4 MCHC-32.9 RDW-14.1
[**2139-9-13**] 12:35PM PT-11.9 PTT-20.7* INR(PT)-1.0
[**2139-9-13**] 12:35PM PLT COUNT-244
[**2139-9-13**] 12:35PM FIBRINOGE-378
[**2139-9-13**] 12:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2139-9-13**] 12:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-9-13**] 12:35PM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2139-9-13**] 12:35PM URINE HYALINE-0-2
Brief Hospital Course:
83 year old female with h/o mild Alzheimer's disease,
CEA in 05, HTN, elev lipids, bladder CA, who presents as a
transfer from OSH with unresponsive with fixed dilated pupils,
decerebrating postering and very extensive R intra cranial
hemorrhage on CT, with significant shift and uncal herniation;
deemed non-operable by neurosurgery and incompatible with
survival. Patient was made CMO by family and expired the
following day.
Medications on Admission:
HCTZ 25mg QD
Zetia 10mg QD
Amlodipine 10mg QD
Plavix 75mg QD
Synthriod 100mg QD
Atenolol 50mg QD
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
large brain hemorrhage
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2139-9-22**]
ICD9 Codes: 431, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4459
} | Medical Text: Admission Date: [**2132-10-27**] Discharge Date: [**2132-11-4**]
Date of Birth: [**2056-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
murmur
Major Surgical or Invasive Procedure:
[**2132-10-30**] Bentall Procedure (25mm St. [**Male First Name (un) 923**] Aortic Valve Graft)
History of Present Illness:
76 y/o male who found to have a murmur on his routine physical
exam. He then underwent an echo which revealed a dilated aorta
and aortic insufficiency. He was then referred for surgery.
Past Medical History:
Deep Vein Thrombosis, Arthritis, Melanoma s/p excision,
Hydrocele, Glaucoma, s/p Appendectomy, s/p Hernia repair
Social History:
Tobacco: 4 pipes/day
ETOH [**11-20**] glasses of scotch/day
Retired, lives at home with wife
Family History:
Father died of aortic aneurysm at 66. 3 cousins died of aortic
anuerysms between 40-50.
Physical Exam:
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, bruits
Pulm: CTAB -w/r/r
Heart: RRR 3/6 murmur
Abd Soft, NT/ND, +BS
Ext: Warm, bilat varicosities, [**11-20**]+ edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2132-11-3**] 03:59PM BLOOD WBC-10.2 RBC-3.57* Hgb-11.5* Hct-33.5*
MCV-94 MCH-32.3* MCHC-34.4 RDW-13.1 Plt Ct-276#
[**2132-10-27**] 08:45PM BLOOD WBC-6.8 RBC-4.07* Hgb-13.7* Hct-38.9*
MCV-96 MCH-33.6* MCHC-35.1* RDW-13.1 Plt Ct-235
[**2132-11-4**] 06:40AM BLOOD PT-19.9* PTT-65.7* INR(PT)-1.9*
[**2132-11-2**] 06:34PM BLOOD PT-19.8* PTT-36.0* INR(PT)-1.8*
[**2132-11-2**] 07:55AM BLOOD PT-18.3* INR(PT)-1.7*
[**2132-11-1**] 08:25AM BLOOD PT-17.4* INR(PT)-1.6*
[**2132-10-30**] 01:15PM BLOOD PT-14.5* PTT-43.9* INR(PT)-1.3*
[**2132-10-27**] 08:45PM BLOOD PT-14.2* PTT-29.2 INR(PT)-1.2*
[**2132-11-3**] 01:02PM BLOOD Glucose-134* UreaN-14 Creat-0.8 Na-132*
K-4.2 Cl-96 HCO3-26 AnGap-14
[**2132-10-27**] 08:45PM BLOOD Glucose-132* UreaN-10 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
[**2132-10-27**] 08:45PM BLOOD ALT-16 AST-23 AlkPhos-67 Amylase-40
TotBili-0.6
[**2132-10-27**] 08:45PM BLOOD Lipase-34
[**2132-11-3**] 01:02PM BLOOD Mg-2.0
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2132-11-3**] 2:17 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p bentall
REASON FOR THIS EXAMINATION:
evaluate effusion
INDICATION: Status post Bentall. Assess effusion.
COMPARISON: [**2132-11-1**].
PA AND LATERAL CHEST: Sternal wires and the valve prosthesis are
unchanged from the prior exam. There is similar cardiomegaly and
tortuosity of the aorta. There are small bilateral pleural
effusions. No pneumonia, failure, or pneumothorax.
IMPRESSION: No short interval change in the appearance of the
chest, with small bilateral pleural effusions.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 18940**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18941**] (Complete)
Done [**2132-10-30**] at 10:49:03 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2056-7-16**]
Age (years): 76 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Left ventricular function.
Valvular heart disease.
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2132-10-30**] at 10:49 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
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 #: 2007AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Sinus Level: *4.5 cm <= 3.6 cm
Aorta - Ascending: *6.5 cm <= 3.4 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Markedly dilated
ascending aorta. Mildly dilated descending aorta. Simple
atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. Moderate to severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderately
thickened mitral valve leaflets. Mild mitral annular
calcification. Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic 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 TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. 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
and cavity size are normal. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is markedly
dilated The 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
moderately thickened. There is no aortic valve stenosis.
Moderate to severe (3+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
are moderately thickened. Physiologic mitral regurgitation is
seen (within normal limits). There is no pericardial effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function
2. Mechanical prosthesis in aortic position. Weall seated and
stable.
3. Trace AI
4. Tube graft in ascending aortic position.
No other change
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Cardiology Report ECG Study Date of [**2132-10-30**] 2:34:56 PM
Baseline artifact. Sinus rhythm. Non-diagnostic Q waves in
leads II, III and aVF with probable ST-T wave abnormalities.
However,
artifact precludes clear visualization of the ST segments. Early
R wave
progression. Precordial T wave inversions. There is a single
atrial premature
beat. Since the previous tracing of [**2132-10-28**] the atrial
premature beat is new
and is probably paced. Inferior ST-T wave abnormalities may have
appeared as
well as the inferior Q waves. Clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 0 88 398/426 0 7 17
Brief Hospital Course:
Mr. [**Known lastname **] was admitted pre-operatively for further cardiac
work-up and to initiate Heparin therapy (d/t pt. previously
being on Coumadin). On [**10-30**] he underwent a cardiac cath which
ruled out any coronary artery disease, but did reveal AI and a
dilated aorta. On [**10-30**] he was brought to the operating room
where he underwent a Bentall procedure. Please see op note for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on beta
blockers and diuretics and gently diuresed towards his pre-op
weight. Later on this day his chest tubes were removed and he
was transferred to the SDU for further care. Coumadin was
initiated and Heparin was used as a bridge until patient was
therapeutic. Epicardial pacing wires were removed per protocol.
Physical therapy worked with him on strength and mobility. He
was ready for discharge to rehab on POD 5. Plan for follow up
at rehab for coumadin dosing, he has received 4mg [**2041-10-31**], 5mg
[**11-3**], 7.5mg [**11-4**]. first draw wednesday [**11-5**] at rehab.
Medications on Admission:
Xalantan gtts, Coumadin (stopped 1 wk before admission),
Prednisone (stopped 2 wks before admission), Timolol gtts,
Alphagan gtts
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a
day: please dose based on INR - draws mon/wed/fri goal INR
2.5-3.0 mech AVR .
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed. Tablet(s)
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Ascending Aortic Aneurysm, Aortic Insufficiency s/p Bentall
Procedure
PMH: Deep Vein Thrombosis, Arthritis, Melanoma s/p excision,
Hydrocele, Glaucoma, s/p Appendectomy, s/p Hernia repair
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] after discharge from rehab
Labs: PT/INR mon/wed/fri for dosing - goal 2.5-3.0 for
mechanical aortic valve
Completed by:[**2132-11-4**]
ICD9 Codes: 5119, 4241, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4460
} | Medical Text: Admission Date: [**2149-5-7**] Discharge Date: [**2149-5-9**]
Date of Birth: [**2068-8-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
radiofrequency ablation
hypertension
Major Surgical or Invasive Procedure:
radiofrequency ablation [**2149-5-7**]
History of Present Illness:
Mrs. [**Last Name (STitle) **] is a pleasant 80yoF with a history of carcinoid s/p
ilial resection and now radio-frequency ablation of a known
liver metastasis, depression, OSA, hypothyroidism, breast cancer
s/p resection/radiation, who is admitted to the ICU following
her liver met RFA with hypertension to the 240s/160s and
hypoxia.
.
Her presentation began with chronic abdominal pain, diarrhea and
vomitting in the early in the early [**2137**] for which she was
frequently hospitalized. She underwent ex-laparotomy in [**2140**]
with a resection of her terminal ilium which pathology revealed
as carcinoid tumor. Following surgery, the patient had almost
complete resolution of her symptoms. However, she continued to
have mild diarrhea in the form of one to two episodes a day and
this frequency slowly increased over the years. She underwent a
negative GI workup with her outpatient gastroenterologist. She
developed sweating and flushing. An abdominal CT in [**9-/2148**]
showed a 2cm solitary liver lesion suspicious for a met, and it
enhanced on an octreotide scan in [**10/2148**] that otherwise showed
no other metastatic burden. Biopsy around that time showed
metastatic carcinoid. She did have a hospitalization for
hypertensive urgency and thereafter began octreotide depot
injections. Due to incomplete control over her symptoms over
the following months, she was referred for selective management
of the liver mass with RFA.
.
She underwent uncomplicated RFA on [**2149-5-7**]. Post-procedure, she
was noted to have increasingly labile blood pressures with a
peak of 240/160. She developed a new oxygen requirement,
saturating in the low nineties on 4LNC. Of note, she uses
home-oxygen set at 5L with activity. She does not require oxygen
at rest. She does have baseline pulmonary dysfunction of unclear
etiology as her [**Name (NI) 11149**] are reportedly normal.
.
On transfer to the ICU, her initial vital signs were: T 96.3
BP142/54 P64 RR19 Sat96/4LNC. She is comfortable and
sleeping. She has no lingering pain from her procedure. She
had mom[**Name (NI) 12823**] chest pain post procedure lasting a few seconds.
No headaches or confusion. Denying current chest pain or
pressure, no shortness of breath. No abdominal pain, nausea,
vomiting. No hematuria, dysuria.
Past Medical History:
adapted from recent oncologist note, confirmed for accuracy with
patient.
- Carcinoid as above
- Early stage breast cancer noted on screening mammogram treated
with resection and radiation. Core biopsy [**8-/2145**] demonstrated
grade I, ER and PR positive, HER-2 negative invasive ductal
carcinoma. She underwent left partial mastectomy 10/[**2144**].
Pathology confirmed Stage I grade 1 invasive ductal carcinoma
with papillary features but without angiolymphatic invasion.
Reexcision for close margins showed no evidence of residual
cancer. Recieved 6100cGy radiation therapy to left breast and
axilla from [**11/2145**] to [**1-/2146**] (No lymph node sampling.)
- Hx of lung nodules followed with imaging which resolved on
chest CT [**2148-8-28**]. [**2137-12-21**] CT showed a 1.2 cm partially
solid nodule in the right lower lobe, stable compared to CT
[**2147-6-7**]. CT [**2148-2-26**] showed a 6 mm right lower lobe
nodule diminished in size and c/w with inflammation.
- Arthritis/DJD
- Asthma
- History of O2 desaturation (to 87%) with activity. Followed
with [**Year (4 digits) 11149**].
- Sleep apnea. Uses CPAP since [**2145**]
- Depression.
- Hypothyroidism since the age of 36.
- Sjogren's disease
- unspecified "[**Last Name **] problem" followed by cardiology
- hemochromatosis carrier
.
ONCOLOGIC HISTORY: In brief, Ms. [**Known lastname 8071**] is an 80 year old
woman who
neuroendocrine tumor of the ileum with positive lymph nodes
found
on laparotomy in [**2140**] after a prolonged course of abdominal
pain,
diarrhea and vomiting. Following surgery her symptoms improved
but she continued to have mild diarrhea. The frequency increased
from [**12-8**] stools per day after surgery to up to 10 times a day
the
fall of [**2147**]. GI work-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] was negative.
Concurrent with slowly progressive diarrhea, the patient also
reports flushing and sweating which increased significantly over
the past few years. CT [**2148-9-25**] showed a new 2 cm solitary
liver enhancing lesion suspicious for metastasis (CT [**2-13**] to
r/o
aortic aneurysm normal by report). Octreotide scan at the time
demonstrated only the hepatic lesion and biopsy of the liver
lesion [**2148-10-8**], demonstrated metastatic carcinoid. In fall
[**2147**] she also had a hypertensive urgency requiring
hospitalization. The patient started on octreotide 20mg IM
qmonth
in [**10/2148**] and increased to 30mg on [**2149-2-26**] due to lack of
response. Of note, prior to starting octreotide the patient
sought consultation with us [**2149-3-10**]. We found her Chromogranin
A
to be elevated at 17 (normal 1.5 to 15) and started her on short
acting octreotide and increased her long acting octreotide to
40mg qmonth as of [**2149-3-21**].
In further detail-
1. Admission on [**2141-1-12**], for which the patient underwent a
diagnostic laparoscopy with laparotomy and resection of 60 cm of
her ileum in the setting of recurrent partial small bowel
obstruction. At surgery, she was noted to have an apparent
implant within the mesentery, the mesenteric border of the
intestine. The pelvis was free of any evidence of tumor. The
uterus and ovaries were noted to be absent as was the appendix.
The cecum, [**Year (4 digits) 499**], liver, stomach, and the remainder of the small
intestine appeared normal. In the mid to terminal ileum, there
were two areas of carcinomatous involvement of the small
intestine extending into the bowel from the mesentery. There
was
a 3-cm diameter node within the small intestinal mesentery.
There were smaller firm shotty lymph nodes along the superior
mesenteric artery, but it was not clear that these were involved
with carcinoma. Because of the possibility that this
represented
carcinoid, gross resection of all tumor was performed by
performing a resection of the small intestine and the associated
mesentery removing approximately 50 to 60 cm of the ileum.
2. Pathology from the above laparotomy confirmed carcinoid
tumor
in the ileum. The proximal and distal resected margins were
negative for tumor, [**4-12**] lymph nodes were positive for metastatic
carcinoid tumor.
3. On [**2147-1-13**], the patient underwent an endoscopy. This was
done to rule out carcinoid. Biopsies were obtained including a
biopsy of the rectosigmoid [**Year (4 digits) 499**] that was consistent with a
hyperplastic polyp. Minute intramucosal lymphoid aggregate was
identified.
4. On [**2147-2-13**], the patient underwent a biopsy of a hep
positive right lower lobe lesion under CT guidance. This did
not
reveal any evidence of cancer. Multinucleated giant cells as
well as benign appearing epithelial cells and macrophages were
present.
5. On [**2148-9-9**], the patient underwent pulmonary function
testing. This revealed mild airflow limitation on [**Year (4 digits) 11149**] with no
significant improvement post bronchodilator administration.
Notation was made of normal lung volumes. There was moderate
impairment in diffusion capacity. The patient's DLCO was
reported at 49% of predicted. Overall, there were changes in
lung function compared to the previous study performed on
[**2148-4-23**].
6. On [**2148-10-9**], the patient underwent a left liver fine
needle
aspirate that was notable for tumor cells consistent with
carcinoid tumor. The tumor was noted to be low-grade.
7. On [**2148-10-23**], the patient underwent an octreotide scan that
was notable for a small focus of increased tracer uptake in the
anterior aspect of the left liver lobe. No other abnormal foci
were seen in the chest, abdomen, and pelvis.
.
Past Surgical History:
- Left ankle fracture open reduction in [**2141**].
- Abdominal hernia repair [**2142**] after exploratory laparotomy.
- Bladder surgery.
- Cholecystectomy.
- TAH-BSO.
- Lumbar disc repair laminectomy.
- Left knee replacement in [**2146**].
Social History:
Widowed. Lives alone [**Last Name (un) **]. Three children, 12 grandchildren
and 8 great grandchildren.
Former smoker: 37-pack-year history. Quit in [**2117**].
Etoh. about 2 glasses a week.
Family History:
5 siblings. 3 children.
Hemochromatosis: Son, daughter and grandson
Sister: [**Name2 (NI) 499**] cancer in late 60s and uterine cancer
Physical Exam:
Vitals: T 96.3 BP142/54 P64 RR19 Sat96/4LNC
General: she is alert and oriented times three, answering
questions appropriately. Appears fatigued.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles appreciated at the bases but no wheezes
auscultated
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the
right second ICS without radiation.
Abdomen: wound dressing with slight serosang. Implanted
hardware felt at the periumbilical area, says it was hernia
mesh. Mild tenderness in the right, not palpated aggressively
due to carcinoid
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
1. Labs on admission:
[**2149-5-8**] 05:22AM BLOOD WBC-7.9 RBC-3.92* Hgb-12.4 Hct-35.7*
MCV-91 MCH-31.6 MCHC-34.6 RDW-14.1 Plt Ct-181
[**2149-5-8**] 05:22AM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1
[**2149-5-8**] 05:22AM BLOOD Glucose-120* UreaN-12 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2149-5-8**] 05:22AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
.
2 Labs on discharge:
.
3. Imaging/diagnostics:
- CT abdomen: 1. Technically successful radiofrequency ablation
of biopsy-proven enlarging metastatic carcinoid within segment
III for palliative purposes. No immediate post-procedural
complications. 2. Unchanged persistent moderate-to-severe
right-sided hydronephrosis seen on
prior exams with delayed enhancement of the right kidney related
to the
underlying obstruction. Unchanged biliary dilatation of
uncertain etiology. 3. No interval change to two additional
small hypoattenuating subcentimeter hepatic lesions within
segment VII and segment VII/VIII dating back to [**9-25**] [**2147**] CT
exam.
.
Brief Hospital Course:
Mrs. [**Known lastname 8071**] is an 80yoF with carcinoid, depression, OSA, breast
cancer history, asthma, hypothyroidism who is admitted to the
[**Hospital Unit Name 153**] following RFA of a hepatic carcinoid met due to
hypertension and hypoxia.
.
# HYPERTENSION: Labile blood pressue with significant
hypertension is common in carcinoid- the so-called "carcinoid
crisis" that can be precipitated by palpation, anesthesia,
chemotherapy, or occur spontaneously. Her hypertension is most
likely caused by release of a host of neuroendocrine vasoactive
mediators released from these tumors, through possible
mechanical stimulation during RFA or through the anesthesia
induction process. Her BP has since corrected to the normal
range. Continued on IV octreotide, howm antihypertensives, and
one dose of IV hydralazine.
.
# METASTATIC CARCINOID: Now status post radio frequency
ablation of the hepatic met for symptoms despite octreotide.
Will continue her standing pre-procedure doses of octreotide of
100 mg TID.
.
# HYPOXIA: Developed decreased sats prior to [**Hospital Unit Name 153**] transfer,
though improved to the mid-90s on 3L prior to discharge. She
does have a baseline oxygen requirement with activity and a
poorly-described diagnosis of chronic lung disease. Patient
treated with bronchodilators. Spoke to primary care doctor
regarding outpatient follow-up with pulmonologist to workup
underlying lung disease. She will resume her home oxygen upon
discharge.
.
# CONFUSION: She has poor short term memory and is at times has
poor attention. Her daughter verified she is at her baseline
mental status. She received a CT head on [**2149-5-8**] which was
negative for acute hemorrhage.
.
Her additional medical problems were treated with her home
medications without complication.
.
She was DNI but OK to rescusitate for this admission.
Medications on Admission:
-ANASTROZOLE [ARIMIDEX] 1 mg po qd
-CEVIMELINE [EVOXAC] 30 mg po qd
-DILTIAZEM HCL 120 mg po qd
-DIPHENOXYLATE-ATROPINE [LOMOTIL] 2 tablets qid prn diarrhea
-FLUTICASONE-SALMETEROL [ADVAIR DISKUS] [**Hospital1 **]
-FUROSEMIDE [LASIX] 40 mg po qd
-LEVOTHYROXINE 88 mcg po qd
-LISINOPRIL 10 mg po qd
-MONTELUKAST [SINGULAIR] 10 mg po qd
-OCTREOTIDE ACETATE 100mcg 3 times a day
-OCTREOTIDE ACETATE 40 mg depot IM q 3-4 weeks
-OPIUM TINCTURE 10 mg/mL - 0.2-0.3 cc(s) by mouth 4-5x/day
-PAROXETINE HCL 20 mg po qd
Discharge Medications:
1. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. cevimeline 30 mg Capsule Sig: One (1) Capsule PO once a day.
3. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. octreotide acetate 100 mcg/mL Solution Sig: One Hundred
(100) mcg Injection Q8H (every 8 hours).
11. octreotide acetate Intramuscular
12. opium tincture 10 mg/mL Tincture Sig: 0.2-0.3 cc PO [**3-11**]
times a day as needed.
13. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hypertension
Hypoxia
Carcinoid tumor
.
SECONDARY DAIGNOSES:
- Arthritis
- Asthma
- Obstructive sleep apnea
- Depression
- Hypothyroidism
- Sjogren's disease
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Ms. [**Known lastname 8071**], you were admitted to the [**Hospital1 827**] because your blood pressure was very high and you
needed supplemental oxygen after your radio-frequency ablation.
Your blood pressure improved and you no longer needed oxygen
prior to discharge. We gave you some pain medications to treat
your abdominal pain. We also scanned your head to make sure you
did not have a bleed, which was negative.
.
Medications:
ADDED:
- Oxycodone 2.5 mg by mouth every 4 hours as needed for pain for
1 week. Please do not drive for operate heavy machinery while on
this medication.
It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
Please make an appointment and follow-up with your primary care
doctor within the next 7 days. Please have him/her help you set
up follow-up appointments with your outpatient pulmonologist
We made you an appointment with your oncologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
When: [**2149-5-21**] @ 8:30 AM
Location: [**Hospital1 18**] - DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 53952**]
Fax: [**Telephone/Fax (1) 13345**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2149-5-10**]
ICD9 Codes: 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4461
} | Medical Text: Admission Date: [**2165-9-26**] Discharge Date: [**2165-10-4**]
Date of Birth: [**2091-1-7**] Sex: F
Service: MEDICINE
Allergies:
Peanut
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
hypoxia, cellulitis
Major Surgical or Invasive Procedure:
intubation [**Date range (3) 19375**]
History of Present Illness:
HPI: 74yo F w/hx of COPD, depression, anxiety, recent cellulitis
presented to PCP today for medical concerns of cellulitis. Pt
had last been seen on [**2165-8-12**] during which time she had
bilateral leg cellulitis and hypoxia (78% on 2L nc). It was
recommended that she be admitted and pt refused. Was prescribed
Keflex with VNA services. Later refused VNA visits and canceled
future appointments. When seen in [**Hospital 191**] clinic today. She was
hypoxic 70% on 2L and cyanotic; she was agreeable to
hospitalization.
.
In ED; The patient was started on Vanc and Zosyn. CTA showed no
PE but a focal linear density in the aorta concerning for
dissection vs small mural thrombus. Vascular and CT surgery
consulted thought that the patient likely had a mural thrombus,
that no surgery would be performed and that medical managment
was appropriate. EKG showed J-point elevation in anterior leads,
? STEMI, cards reviewed EKG and thought there might be some
ischemic changes but that no intervention was necessary. The
patient was given steroids and continuous nebs. As her ABG did
not improve, she was placed on CPAP. She continued to fatigue
and had rising pCO2. She was then intubated and admitted to the
MICU.
Past Medical History:
COPD, on O2 at home (2L, recently increased to 4L)
Depression
Anxiety
Osteopenia
Tobacco Abuse
Social History:
Pt had been previously estranged from family and now has
re-established contact. [**Name (NI) **]-term and current smoker.
Family History:
NC
Physical Exam:
T: 98.6 129-140/60-78 HR:80-82 RR:24 91% 4L
Gen: Thin woman, sitting in chair, on 4L NC, tachypnic
Neuro: AAOx3. Biceps and patellar reflexes unable to be
elicited due to position. CN II-VI: PERRL, EOMI. CN V: Facial
sensation symmetric
CN VII: Strength intact with eyebrow raise, cheek puff. CN VIII:
Hearing intact via tuning fork bilaterally. CN IX/X: Uvula
midline. CN [**Doctor First Name 81**]: Intact via shoulder shrug. CN XII: tongue
midline.
HEENT: Nose and lips cyanotic. No lymphadenopathy. Oropharynx
without lesions or exudate
CV: Regular rate and rhythm. No murmurs appreciated.
Lung: Bilateral inspiratory wheezing, good aeration with effort.
No egophony noted.
Abd: soft, non-tender, non-distended. Small ecchymoses from SQH
Ext: Lower legs with gauze dressing. Warm to touch. Radial
pulses strong.
Pertinent Results:
[**2165-10-4**] 05:20AM BLOOD WBC-9.7 RBC-5.45* Hgb-17.9* Hct-55.4*
MCV-102* MCH-32.9* MCHC-32.4 RDW-14.1 Plt Ct-149*
[**2165-10-3**] 05:00AM BLOOD PT-13.0 PTT-29.9 INR(PT)-1.1
[**2165-10-3**] 05:00AM BLOOD Ret Aut-0.5*
[**2165-10-4**] 05:20AM BLOOD Glucose-108* UreaN-33* Creat-0.8 Na-143
K-3.8 Cl-103 HCO3-35* AnGap-9
[**2165-10-2**] 11:43AM BLOOD CK(CPK)-30
[**2165-10-2**] 11:43AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2165-10-4**] 05:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
[**2165-10-3**] 05:00AM BLOOD VitB12-795 Folate-13.2
[**2165-10-2**] 08:15AM BLOOD %HbA1c-6.3*
[**2165-10-1**] 01:12PM BLOOD Type-ART pO2-62* pCO2-66* pH-7.37
calTCO2-40* Base XS-9
[**2165-9-28**] 12:42AM BLOOD Lactate-1.4
.
[**2165-9-30**] 4:40 pm RAPID RESPIRATORY VIRAL ANTIGEN TEST: NEG
.
GRAM STAIN (Final [**2165-9-30**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2165-10-2**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
.
URINE CULTURE (Final [**2165-10-1**]): NO GROWTH.
Blood Cx: [**9-26**], [**9-28**], [**9-30**] NGTD
.
[**2165-9-26**]: CXR: bibasilar atelectasis
.
Echo [**2165-8-9**]: Hyperdynamic left ventricular systolic function.
EF > 75%. Probable mild diastolic dysfunction. No significant
valvular abnormality seen. Moderate pulmonary artery systolic
hypertension.
.
LE U/S [**2165-7-25**]: no DVTs
.
ECG Sinus tachycardia. Poor R wave progressio. Consider prior
anteroseptal
myocardial infarction. Left atrial abnormality. Compared to
tracing #2
no change.
Brief Hospital Course:
Mrs. [**Known lastname 19376**] was admitted to the MICU for respiratory failure
in the setting of COPD, continued smoking and possible pneumonia
seen on CXR. CTA was negative for PE, but showed possible mural
thrombus. Medical managment was recommended. Echocardiogram
did not show new heart failure. She was put on standing nebs,
Solumedrol 125mg IV q8 hours, Levofloxacin for PNA and
Vancomycin for her cellulitis. She was transitioned to Unasyn
on [**2165-9-30**] after sputum and blood cultures were negative. Her
respiratory status improved and she was extubated on [**2165-10-1**].
She was then transitioned to PO Augmentin and should complete a
14 day course. (Last day of abx = [**2165-10-10**]). She was diuresed
with IV Lasix and then put on Lasix 20mg PO qday which should be
continued after discharge for edema and heart failure.
Theophylline was held due to concerns for drug interactions.
Her legionella antigen was negative and sputum cultures were
negative.
.
For her cellulitis, wound care evaluated Ms. [**Known lastname 19376**] and
recommendations are below. She continued on antibiotics and was
given Lasix to remove fluid. She was negative 5 liters over the
course of her MICU stay.
.
On [**2165-10-2**], she was complaining of chest pressure which she
related to heartburn. ECG was done and was negative for any
changes suggestive of ischemia. She had cardiac enzymes which
were negative X 1.
.
After extubation, she did well was changed to PO Prednisone 40mg
a day. She will then be tapered over 2 weeks. She has a 4L
oxygen requirement and saturations range between 87-92% at
baseline. She is appropriately compensated and stable within
this range.
.
She had elevated blood glucose levels and was started on
Glargine 8 units at night as well as a sliding scale insulin.
Her blood sugars improved as the steroids were tapered.
.
Mrs. [**Known lastname 19376**] was seen by a social worker for depression and
medication non-compliance. She was restarted on Clonazepam
0.5mg on [**2165-10-2**].
Medications on Admission:
Albuterol 90mcg inhaler, 2 puffs q4-6 hours PRN
Clonazepam 1mg PO qday
Ipratropium 17mcg inh 2 puffs q4-6hours PRN (pt not taking)
Duoneb nebulized solution
Theophylline 300mg PO BID
Cetirizine 10mg PO qday PRN
Oxygen 2-4L
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day) for 2 weeks.
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) Units
Subcutaneous at bedtime for 3 weeks: titrate down as steriods
are tapered.
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day as needed for
hypergylcemia: Sliding scale:
FS <150: zero
150-200: 2U
200-250: 4U
250-300: 6U
300-350: 8U
350-400: 10U
>400: [**Name8 (MD) **] Md.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 2 days.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation QAM (once a day (in the morning)).
13. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs
Inhalation QID (4 times a day) as needed.
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO daily:prn.
17. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
20. Prednisone 10 mg Tablet Sig: follow directions Tablet PO
once a day for 16 days: Taper:
40mg daily x 1 day
30mg daily x 4 days
20mg daily x 4 days
10mg daily x 4 days
5mg daily x 3 days.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Primary:
Hypoxia secondary to COPD exacerbation
Lower ext. cellulits
Secondary:
COPD
Depression
Anxiety
Osteopenia
Tobacco Abuse
Discharge Condition:
stable, normotensive, on 4L NC satting 87-92% at baseline,
afebrile
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because your breathing
difficulty and an infection in your skin. You were in the
intensive care unit for your breathing difficulty and were
intubated. You improved and were able to be taken off the
breathing machine and sent out of the ICU. You were back to
your normal 4L of O2 upon discharge and your O2 saturation
ranged btw 87-92%.
For your skin infection in your legs you were treated with
antibiotics and will continue those antibiotics for a 14 day
course.
You should have outpatient Pulmonary function test when
discharged from rehab and back to your baseline pulmonary
status.
Please follow the medications prescribed below.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 10778**] [**Name11 (NameIs) 10779**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2165-10-9**] 3:20
Provider: [**Name10 (NameIs) 10778**] [**Name11 (NameIs) 10779**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2165-12-20**] 2:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2165-10-7**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4462
} | Medical Text: Admission Date: [**2172-12-30**] Discharge Date: [**2173-1-6**]
Date of Birth: [**2114-6-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CABG x 3 (LIMA to LAD, SVG to OM & PDA)
History of Present Illness:
This is a 58 y/o male with no known h/o CAD who reported
exertional CP x several yrs w/ worsening angina over past 4 wks.
Now occuring at rest and assoc. w/ SOB. ETT in [**12-29**] showed +
mild reversible post. defect. Cath at OSH showed 90% LM stenosis
and Carotid U/s 80-99% [**Doctor First Name 3098**] stenosis. Transferred to [**Hospital1 18**] on
[**2172-12-30**] for eval/tx of carotid dz and CABG.
Past Medical History:
HTN
^chol
Gout
s/p L4-L5 Laminectomy '[**52**]
s/p R Knee surgery '[**62**]
Social History:
Lives in [**Location 15852**], NH with wife. [**Name (NI) **] full-time as mechanic.
Quit smoking 30 yrs ago. <15 yr pk hx. 2 glasses wine w/ dinner.
Family History:
+CAD hx. Brother w/ CABG in 40's. Father died of MI in 60s
Pertinent Results:
Pre-op EKG: 57 Sinus bradycardia, Early transition, Consider
true posterior myocardial infarct
[**2172-12-30**] 05:40PM BLOOD WBC-5.6 RBC-4.64 Hgb-14.9 Hct-42.9 MCV-93
MCH-32.0 MCHC-34.7 RDW-12.9 Plt Ct-211
[**2173-1-6**] 06:35AM BLOOD WBC-6.7 RBC-3.13* Hgb-10.0* Hct-28.6*
MCV-91 MCH-31.9 MCHC-34.9 RDW-13.3 Plt Ct-214#
[**2172-12-30**] 05:40PM BLOOD PT-13.3 PTT-34.9 INR(PT)-1.1
[**2172-12-30**] 05:40PM BLOOD Plt Ct-211
[**2173-1-6**] 06:35AM BLOOD Plt Ct-214#
[**2172-12-30**] 05:40PM BLOOD Glucose-106* UreaN-16 Creat-1.2 Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
[**2173-1-6**] 06:35AM BLOOD Glucose-97 UreaN-24* Creat-1.2 Na-139
K-4.3 Cl-103 HCO3-29 AnGap-11
[**2172-12-31**] 06:25AM BLOOD ALT-34 AST-30 LD(LDH)-196 AlkPhos-60
Amylase-47 TotBili-0.3
[**2173-1-1**] 12:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.034
[**2173-1-1**] 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
After admission on [**2172-12-30**], pt was brought to the cath lab on
[**12-31**] and found to have no angiographically significant carotid
artery disease. And placement of an intraaortic balloon pump due
to LM Dz. The next day he was brought to the OR and after
general anesthesia, he underwent a coronary artery bypass graft
x 3 (LIMA to LAD, SVG to OM & PDA). Please refer to OP summary
for full surgical details. Pt. tolerated the procedure well and
was transferred to CSRU in stable condition. His MAP was 102,
CVP 12, PAD 17, [**Doctor First Name 1052**] 22, HR 88 A-Paced and was being titrated on
Propofol and Neosynephrine. Later that day propofol was weaned
and pt. was extubated. He was alert, oriented and neurologically
intact.
POD #1 - Neo was weaned off. IABP was removed w/out incident.
POD #2 - Pt. doing well in CSRU and was then transferred to
telemetry floor.
POD #3 - Chest tubes, pacing wires, foley removed. Pt.
hemodynam. stable. Lopressor was increased and pt. cont. to
receive lasix.
POD #4 - Pt. improving well. Ambulating good. PE unremarkable
besides trace edema. hemodynam. stable. lopressor increased to
75 [**Hospital1 **]. Lasix changed to po.
POD #5 - Pt. d/c'd home today w/ VNA services. Looked well. Had
uncomplicated post-op course.
D/C PE:
VS: T 99.2 P 69SR BP 128/73 RR 20
Neuro: alert, oriented, non-focal
Pulm: CTAB
Cardiac: RRR
Chest: Sternum stable, -erythema/drainage
Abd: soft NT/ND +BS
Ext: L. leg inc. C/D/I
Medications on Admission:
Meds at transfer: IV Nitro, Heparin, Atenolol, [**Hospital1 **], Zetia
Meds at home: [**Last Name (LF) **], [**First Name3 (LF) **]
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(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. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 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) 1514**] [**Last Name (un) **] VNA
Discharge Diagnosis:
CAD s/p CABG x 3 (LIMA to LAD, SVG to OM & PDA)
HTN
^chol
Gout
s/p L4-L5 Laminectomy '[**52**]
s/p R Knee surgery '[**62**]
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no lifting > 10# or driving for 1 month
no creams or lotions to incisions
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**1-7**] weeks
with Dr. [**Last Name (STitle) 70**] in [**4-9**] weeks
Completed by:[**2173-1-28**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4463
} | Medical Text: Admission Date: [**2124-3-28**] Discharge Date: [**2124-4-14**]
Date of Birth: [**2047-6-24**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This patient is a 76 year old
male with known left bundle branch block who was admitted to
the Medical Service for increasing exertional arm and back
pain. Associated symptoms were dyspnea on exertion.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of malaria.
3. Gastroesophageal reflux disease.
4. Barrett's esophagus.
5. Colonic polyps.
6. Iron deficiency anemia.
7. History of proteinuria.
8. History of asbestos exposure.
PAST SURGICAL HISTORY: Unremarkable.
MEDICATIONS ON ADMISSION:
1. Protonix 20 mg p.o. q. day
2. Iron Sulfate
3. Lisinopril
ALLERGIES: Lobster.
SOCIAL HISTORY: Unremarkable.
PHYSICAL EXAMINATION: The patient, on physical examination,
was afebrile with vital signs stable. Head was atraumatic,
normocephalic. No scleral icterus noted. Neck was soft,
supple, no carotid bruits noted. Heart was regular rate and
rhythm with a II/VI systolic ejection murmur noted. Chest
was clear to auscultation bilaterally. Abdomen was soft,
nontender, nondistended, positive bowel sounds. Extremities
with no edema. Pulse examinations were palpable throughout
bilaterally.
HOSPITAL COURSE: The patient was admitted on [**2124-3-28**] to the Medical Service and taken for cardiac
catheterization which revealed a 50% occlusion of the left
main, 80% occlusion of the ostial left anterior descending,
95% occlusion of the left circumflex and 100% occlusion of
the mid right coronary artery. In addition, echocardiogram
in [**2124-2-10**] revealed an ejection fraction of 25%, global
left ventricular hypokinesis and mild diastolic aortic root,
trace aortic regurgitation, 2+ mitral regurgitation and 2+
tricuspid regurgitation. Cardiac Surgery was consulted on
the date of admission for evaluation and treatment via
possible coronary artery bypass graft.
At this time, the patient also had ongoing medical problems
including renal insufficiency with a creatinine up to 2.0 and
iron deficiency anemia. At this time ACE inhibitor was held
and the patient was gently hydrated with 1/2 normal saline.
Between the date of admission and [**2124-4-2**], the
patient's chronic renal insufficiency appeared to stabilize
with a creatinine approximately between 1.8 and 2.0. During
this interval time, the patient was approached and options
for surgery were discussed. The patient agreed to surgery on
[**2124-4-3**] and went to the Operating Room for coronary
artery bypass graft times four, left internal mammary artery
to left anterior descending, saphenous vein graft to ramus,
saphenous vein graft to obtuse marginal and saphenous vein
graft to right coronary artery. For more details, please see
operative report.
Postoperatively, the patient went to the Cardiac Surgery
Recovery Unit. On postoperative day #0 the patient was noted
to be in accelerated junctional rhythm, however, when his
rate slowed down the patient would commence to enter complete
heartblock. The patient lost his atrial fibrillation with P
pacing and was unable to A pace when in complete heartblock.
His blood pressure remained labile, sensitive to rate and
rhythm changes and was being managed with Levophed GTT. On
postoperative day #1, the patient was on Levophed and
Milrinone drips with a pressure in the 1-teens. The patient
was extubated on postoperative day #1 and pressors were
continuously weaned over the day which the patient tolerated
well. On postoperative day #2, the patient went into atrial
fibrillation with the rates in the 130s to 140s, otherwise
hemodynamically stable. The patient was treated with
Lopressor 2.5 mg intravenously times two with good effect,
heart rate decreasing to the 1-tens. The pacer settings were
changed appropriately and Amiodarone bolus 150 mg was given.
The patient converted to a rate of 40s to 50s with Amiodarone
bolus and required A pacing to maintain blood pressure and
indices. Amiodarone drip was started shortly thereafter.
The patient was diuresed over the next several days with good
effect. Creatinine was stable at 1.9 to 2.0.
On postoperative day #4, the patient again went into atrial
fibrillation and Amiodarone bolus was once again given. The
patient went back into normal sinus rhythm and the patient
was on p.o. Amiodarone. On postoperative day #5, later in
the day the patient was put on a heparin drip. On
postoperative day #6, the patient was transferred to the
floor, and on postoperative day #7 the patient was started on
Coumadin with a therapeutic range of 2.0. Of note, as well
is that postoperative echocardiogram revealed an ejection
fraction of 15 to 20%. The remainder of the [**Hospital 228**]
hospital course was unremarkable. The patient remained in
sinus rhythm with being loaded for Coumadin with INRs being
checked daily and in the meantime being on a heparin drip.
On postoperative day #11, the patient's INR was reacting
appropriately to Coumadin dosing at 1.6. The patient was
still on a heparin drip. The patient was deemed well enough
to go home with services with Lovenox to bridge the patient
until he was therapeutic.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Chronic renal insufficiency.
3. Hypertension.
4. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q. day
3. Percocet 1 to 2 tablets p.o. 4-6 hours prn for pain
4. Metoprolol 12.5 mg p.o. q. day, extended release.
5. Amiodarone 400 mg p.o. b.i.d. times one week, then 400 mg
p.o. q. day times one week and then 200 mg p.o. q. day.
6. Nexium 40 mg p.o. q. day.
7. Coumadin 5 mg p.o. q.h.s. with therapeutic INR of 2.0.
8. Iron sulfate 325 mg p.o. b.i.d.
9. Lovenox dosed for b.i.d. dosing times three days.
FOLLOW UP: The patient is to follow up in [**Hospital 409**] Clinic in
two weeks, Dr. [**Last Name (STitle) 5717**] in three to four weeks and also for INR
checks, Dr. [**Last Name (STitle) **] on [**5-1**], Dr. [**Last Name (STitle) **] in the
Electrophysiology Clinic in one month and Dr. [**Last Name (STitle) 70**] in
six weeks.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2124-4-14**] 10:16
T: [**2124-4-14**] 10:40
JOB#: [**Job Number 52346**]
ICD9 Codes: 9971, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4464
} | Medical Text: Admission Date: [**2158-3-14**] Discharge Date: [**2158-3-19**]
Date of Birth: [**2094-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cefepime
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Rigors.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 65370**] is a very nice 63 year-old woman with history of
schizoid personality, CAD s/p stent ([**2154**]), CHF (EF ~10%?), h/o
cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%, Atrial Fibrillation not on
coumadin, chronic L-side pleural effusion and h/o multiple UTIs
who comes complaining of chills and vomit. She was in her prior
state of health at [**Hospital 11851**] Healthcare until last night when
she woke up feeling very cold, with chills. She denied having
her temperature taken at that time. She denied fatigue, nausea,
vomit, diarrhea, chest pain, PND, orthopnea, dysuria,
palpitations, SOB. However, she was [**Doctor Last Name **] to BINeedham's ER.
.
She went to [**Hospital1 **]-[**Location (un) 8062**] ER where her initial vital signs showed
fever of 104, tachycardia up to 120s and 83% on RA. She coughed
with blood tinged sputum. She was guaiac positive. Multiple
attempts were done to contact her appointed legal guardian and
messages were left, but doctors were unable to reach him. Her
labs showed HCT of 28, Trop 0.09. She had large bowel movement.
Suspected sepsis with unknown source, but he considered the left
lung or a UTI. Pt received 1 L NS. She received Levo/vanc and
1g of Tylenol and was transfered to [**Hospital1 18**].
.
In the [**Hospital1 1388**] ER her initial VS were T 99.8 F, BP 90/57 mmHg,
HR 112 BPM, RR 22 BPM, 100% 2L NC. Pt had normal physical exam
and reported "melena" in the rectal vault. Got IV access, 2 U
RBC's, IV PPI.
.
Of note she was admitted to [**Location (un) 620**] ~1 month ago and was treated
for E. coli UTI with Bactrim-DS p.o. b.i.d her HCT at that time
was HCT 26 [**2158-2-1**].
Past Medical History:
-Syncope 3yrs ago
.
PAST MEDICAL HISTORY:
-Coronary Artery Disease (3VD, not a surgical candidate, s/p
stent to LCX in [**12/2154**])
-CHF, h/o cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%
-Severe MR, moderate TR
-Atrial fibrillation on amiodarone
-Syncope 3yrs ago
-Neck pain, eval in 2/99 at [**Hospital1 336**] with some fibromyalgia points,
occured after viral syndrome
-Iron deficient Anemia
-Fibromyalgia
-Diverticulosis
-Internal Hemorrhoids
-Osteopenia
-Cluster A personality (schizoid) with question underlying
dementia, court order made for her to be DNR/DNI at last
admission
-Gastritis
-Bursitis
-Adrenal adenoma
Social History:
Patient lives in [**Hospital 11851**] healthcare. She denies any current or
past history of smoking. Used to drink alcohol occasionaly, but
[**Doctor First Name 1638**] any drink for many years. She denies being sexually
active; no inter-personal relationships; no family or friends
involved. She is DNR/DNI (per guardian [**Name (NI) **] [**Name (NI) **]). Pt denies
ilicit substance use.
Family History:
n/c
Physical Exam:
VITAL SIGNS - Temp 98 F, BP 111/61 mmHg, HR 94 BPM, RR 19 X',
O2-sat 96% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, 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. Decreased breath sounds in L
base with decrease conduction of voice in that region.
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). Swelling of both ankles 1+
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-26**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Exam on Discharge: Awake, alert, interactive. Denies complaints.
Lungs CTA B, heart RRR, no m/r/g. Abdomen soft, NTND.
Pertinent Results:
[**2158-3-14**] 04:05AM BLOOD WBC-15.0* RBC-3.80* Hgb-7.8*# Hct-26.0*
MCV-68*# MCH-20.5*# MCHC-30.0*# RDW-18.2* Plt Ct-264
[**2158-3-14**] 04:05AM BLOOD Neuts-94.3* Bands-0 Lymphs-2.4* Monos-3.2
Eos-0.1 Baso-0
[**2158-3-14**] 04:05AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
[**2158-3-14**] 05:05AM BLOOD PT-13.0 PTT-22.1 INR(PT)-1.1
[**2158-3-14**] 04:05AM BLOOD Glucose-166* UreaN-38* Creat-1.0 Na-138
K-3.7 Cl-105 HCO3-21* AnGap-16
[**2158-3-14**] 04:05AM BLOOD ALT-5 AST-11 CK(CPK)-25* AlkPhos-60
TotBili-0.2
[**2158-3-14**] 04:05AM BLOOD cTropnT-0.15*
[**2158-3-14**] 11:44PM BLOOD CK-MB-3 cTropnT-0.05*
[**2158-3-14**] 04:05AM BLOOD ALT-5 AST-11 CK(CPK)-25* AlkPhos-60
TotBili-0.2
[**2158-3-14**] 11:44PM BLOOD CK(CPK)-41
[**2158-3-14**] 04:05AM BLOOD Albumin-3.1* Calcium-7.6*
[**2158-3-14**] 04:05AM BLOOD VitB12-401 Folate-5.7
[**2158-3-14**] 09:09AM BLOOD calTIBC-267 Ferritn-154* TRF-205
[**2158-3-14**] 09:09AM BLOOD Cortsol-25.2*
[**2158-3-14**] 04:12AM BLOOD Lactate-1.4
CXR: IMPRESSION:
1. Probable left pneumonia.
2. Persistent moderate-to-large-size left pleural effusion, at
least partially
loculated, presumably infectious or malignant.
ECG:
Sinus tachycardia. Diffuse low voltage. Baseline artifact.
Compared to the
previous tracing of [**2155-4-25**] the T wave inversion recorded in
leads V2-V5 and Q-T interval prolongation have resolved
consistent with prior recording representing active
anterolateral ischemia. The present findings may represent
pseudonormalization. Followup and clinical correlation are
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 170 92 370/448 60 -24 115
CHEST CT ON [**3-15**]
HISTORY: Fever, chills and large left pleural effusion.
Considering
thoracentesis.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without intravenous contrast [**Doctor Last Name 360**] reconstructed as
contiguous 5- and 1-mm thick axial and 5-mm thick coronal and
paramedian sagittal images read in conjunction with chest
radiographs from [**2154**] and [**2-15**] and [**2158-3-14**].
FINDINGS:
The large left pleural abnormality which increased between
[**2-15**] and [**3-14**] is a lenticular collection, extending
along the left costal pleural margin from the apex to the
diaphragm, occupying approximately half of the volume of the
left hemithorax. The wall of the pleural abnormality is
extremely irregular, ranging up to 3 cm in thickness, including
a high-density inner rind that ranges in attenuation up to 70
[**Doctor Last Name **], consistent with either partial calcification or chronic
organized hematoma. The contents are heterogeneous ranging in
attenuation from [**Doctor Last Name **] 30 to [**Doctor Last Name **] 50, conceivably partially
hemorrhagic as well; since there is no level at the interface
with small pockets of gas in the collection, the contents are
either extremely viscous or not fluid at all. The source of the
gas could be a recent attempt at thoracentesis, communication
with the lung/bronchial tree, or, least common, gas-forming
pleural infection.
The left main and upper lobe bronchi are patent, but the
lingular segmental bronchus is moderately narrowed, and the
superior segment of the left lower lobe, the basal trunk and
basal segmental bronchi are all completely occluded. Whether
this is due to mass effect of the pleural collection or a
combination of mass effect with longstanding atelectasis of the
lower lobe and lingula, and some hilar adenopathy is hard to
say, although a segment of the basal trunk with wall
calcification clearly shows occlusion by material or tissue in
the bronchus at that level.
The left ventricle is very dilated, at the expense of the right
ventricle, and there is extreme thinning and bulging of the
posterior and inferior wall, with perimeter calcification,
either a 5 cm wide aneurysm or wide-mouthed pseudoaneurysm.
There is no pericardial effusion or pericardial calcification.
Although the pericardium appears intact and at most levels, the
left ventricular abnormality is separable from the pleural
collection, for a length of roughly 15 mm, 4A:201-215;
communication at those levels is not excluded. Echocardiography
may help in that regard. Inferior to the contained pleural
abnormality is pleural fluid which permeates the epicardial fat
anteriorly and abuts the posterior reflection of pericardium
posteriorly.
Bronchiolar and acinar nodules are present in large numbers in
the right upper lobe, less so at the base of the right lung.
Wall thickening in small bronchi in both regions is more
pronounced in the latter, suggesting that chronic basal
bronchiectasis may be the source of infection for active
bronchiolitis in the upper lobe. Larger irregular opacities in
the lower lobe are most likely infection or atelectasis, but
need to be followed to prove that. A small right pleural
effusion layers posteriorly.
Atherosclerotic calcification is heavy in the coronary,
innominate and left subclavian. Mediastinal lymph nodes are
mildly enlarged, ranging up to 13 mm, 10 mm, and 9 mm in the
subcarinal, prevascular and right lower paratracheal stations
respectively. Pulmonary arteries are normal in size.
This examination is not designed for subdiaphragmatic evaluation
except to note granulomatous calcification in an otherwise
normal left adrenal gland, no right adrenal mass, and large
cysts in the liver. Engorgement of the hepatic veins suggest
elevated right heart pressures.
IMPRESSION:
1. Large possibly hemorrhagic chronic left pleural collection,
most likely empyema, including tuberculosis.
2. Left ventricular dilatation and large posterior wall aneurysm
or
pseudoaneurysm. Right ventricle may be compromised by left
ventricular
dilatation. Connection between the left ventricle and pleural
collection needs to be evaluated by cardiac imaging starting
with ultrasound, MRI if necessary.
3. Left lower lobe and lingular collapse can be explained by
mass effect from the left pleural collection obstructing the
left bronchial tree distal to the superior division of the upper
lobe.
4. Widespread right lung bronchiolitis, most commonly
non-tuberculous
mycobacterial species, but conceivably pyogenic.
Discharge Laboratories: [**2158-3-18**]
WBC:7.7 Hct:27.6 Plt:289
Na:138 K:4.0 Cl:103 HCO3:27 BUN:14 Cr:1.0UreaN Creat Na K Cl
HCO3
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 65370**] is a very nice 63 year-old woman with history of
schizoid personality, CAD s/p stent ([**2154**]), CHF (EF ~10%?), h/o
cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%, Atrial Fibrillation not on
coumadin, chronic L-side pleural effusion and h/o multiple UTIs
who comes complaining of chills and vomit.
.
#. Urinary Tract Infection - Patient initially found to have BP
slightly below her normal baseline of 80-90s, with chills,
rigors and fever. An infectious workup revealed a dirty UA and
Cx grew pan s e coli. She was treated with levofloxacin and she
quickly improved.
.
#. Chronic Left sided pleural effusion: On arrival to our
hospital the patient was not hypoxemic. She had transient
shortness of breath prior to admission but none here. With her
h/o effusion, a CT scan was done that demonstrated multiple
significant findings that were all suspected to be incidental
and unrelated to her presentation. In her left lung she has a
very large pleural effusion with a 3cm rind on the pleura which
at one location is adjacent to her dilated LV aneurysm. There
was concern that the LV scar and pleural rind are contiguous. An
echo was done, but could not sufficiently exclude this. The case
was discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of thoracic surgery who
suggested that a VATS was insufficient to correct the effusion
due to the thick rind and the patient would require a
thoracotomy. The risks and benefits were discussed with the
patient and her health care proxy and they elected to decline
any surgical intervention. She is DNR/DNI, wheelchair bound, and
denies symptoms of dyspnea so if symptoms later arise this can
be readdressed. Per her primary MD, it has been present for
years. Fluid from tap last year demonstrated a sterile exudative
effusion. No record of malignant cytology. Regardless of the
initial cause, surgical management is the only current option. A
PPD was placed on her R forearm for a low possibility of TB,
which was read as negative on [**2158-3-19**]. This plan for
conservative managment was discussed with Dr. [**Last Name (STitle) **], the
[**Name6 (MD) 228**] primary MD who agrees.
.
Bronchiolitis:In the right lung the patient has some small tree
and [**Male First Name (un) 239**] opacities along with changes consistent with chronic
bronchiectasis and possibly a non-tuberculous mycobacterial
infection. Patient seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of pulmonary
who felt these changes are likely chronic and not responsible
for her sepsis presentation and are not consistent with TB. Plan
to follow clinically. Should she develop worsening cough or
shortness of breath, repeat non-contract chest CT recommended
over routine CXR.
.
#. Acute on Chronic Systolic Heart Failure - Pt with known EF of
10%. Hypotension on admission infection related. Euvolemic on
discharge with mild edema in feet.
.
#. Coronary Artery Disease - 3V and poor surgical candidate with
stent in [**2154**]. On Asa/Plavix. Started a low dose statin as no
record of contraindication.
.
#. Atrial Fibrillation - Continuied amiodarone for rhythm
control. patient not anticoagulated on admission.
.
#. Anemia - Iron studies, B12, folate, all wnl.
.
#. Cluster A (schizoid) personality disorder - well compensated.
flat affect, but no psychosis features.
.
#. CODE: Patient was DNR/DNI during this admission, which was
reversed by order or the patient's guardian, [**Name (NI) **] [**Name (NI) **], prior to
discharge. She is now Full Code.
Medications on Admission:
* Plavix 75 Daily (per patient's report
* Vitamin C 500 mg PO Daily
* Senna 8.6 mg PO Daily PRN
* Roxonal 10 mg q4 hrs PRN pain
* MS Contin 30 mg PO QHS
* Aspirin 325 mg PO Daily
* Albuterol inhaler 3 ml PO Qhr PRN resp distress
* Calcium carbonate 500 mg PO Q4 hrs PRN GI upset
* Allopurinol 1 PO Daily
* Tylenol 325 mg PO 1-2 tabs q4 hrs PRN Temp
* Lasix 80 mg PO Daily
* Prilosec 40 mg PO Daily
* Amiodarone 200 mg PO daily
* Klor-Con 8 mEq
* Colace 100 mg PO BID
* Levorhtyroxine 25 mcg PO Daily
* Fregon 27 mg PO TID
* Bisacodyl rectally as needed
* Hyoscyamine 0.125 SL Q4hrs PSN secretions
* Milk of magnesia susp 30 mg PO Daily PRN constipation
* Fluticasone 50 1 Spray at baseline
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB / Wheezing.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for Reflux.
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or fever.
11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Klor-Con 8 8 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
16. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Fergon 240 mg (27 mg Iron) Tablet Sig: One (1) Tablet PO
three times a day.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
19. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual every four (4) hours as needed for secretions.
20. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
21. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis: 599.0 URINARY TRACT INFECTION, BACTERIAL
Secondary Diagnosis: 511.9 EFFUSION, PLEURAL
Secondary Diagnosis: 414.01 CAD, NATIVE VESSEL
Secondary Diagnosis: 428.20 HEART FAILURE, (A3) CHRONIC SYSTOLIC
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 244.9 HYPOTHYROIDISM
Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
Secondary Diagnosis: 466.19 AC BRONCHIOLITIS D/T OTH INF ORG
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:
patient being discharged to a facility
Followup Instructions:
Should the decision for surgical management change, please
contact:
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Thoracic Surgery ([**Telephone/Fax (1) 17398**].
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Pulmonary ([**Telephone/Fax (1) 65371**].
ICD9 Codes: 0389, 5990, 5119, 4280, 412, 4240, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4465
} | Medical Text: Admission Date: [**2118-7-27**] Discharge Date: [**2118-7-30**]
Date of Birth: [**2048-9-24**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 70-year-old white female
was noted to have an occipital headache earlier last night
with an associated blackout spell briefly. She was brought to
an outside hospital with a CT scan evidence of ascending
aortic aneurysm with possible thrombus in her descending
aorta per report.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
PAST SURGICAL HISTORY: Right shoulder arthroscopy.
ALLERGIES: No known drug allergies.
PRE-ADMISSION MEDICATIONS:
1. Norvasc.
2. Lipitor.
3. Lopressor.
4. Imipramine.
5. An antidepressant, which the patient could not remember
the name of, possibly Paxil.
PHYSICAL EXAMINATION: On emergency examination she was noted
to be appropriate only in mild distress, 91 heart rate in
sinus rhythm, blood pressure 121/71, oxygen saturations 97%
on 6 liters of oxygen. GENERAL: She was alert and oriented x
3. HEENT: Neck was supple without bruits. CHEST: Clear to
auscultation with slightly decreased breath sounds at the
base. HEART: Regular rate and rhythm with S1 and S2 with no
murmur, rub or gallop. ABDOMEN: Slightly obese, soft,
nontender, nondistended with 2+ left femoral, 2+ right
femoral, 2+ left DP, 2+ right DP, 2+ left radial, 1+ right
radial pulses. NEUROLOGIC: Nonfocal neurologic examination.
Chest x-ray showed a large mediastinum consistent with
ascending aortic aneurysm. CT scan at the outside hospital
showed 8 cm ascending aorta with question of a leak and
evidence of pericardial effusion and apparently an intramural
thrombus possibly in the descending thoracic aorta, no double-
lumen with contrast was seen, coupled with distention with
aneurysm 6 to 7 cm. Thus she was submitted for her possible
type B dissection and started on Labetalol drip for blood
pressure control. Echocardiogram was ordered. She was seen by
pulmonary medicine for hypoxia and shortness of breath
preoperatively. She was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **],
for possible repair of ascending versus descending thoracic
aneurysm and her aortic dissection. Pulmonary embolus
evaluation was done on the differential diagnosis for shunt
and with CT angio also to be done. Please refer to the
official pulmonary consult report by Dr. [**Last Name (STitle) **].
Preoperative labs were as follows: White blood cell count
9.6, hematocrit 36.0, platelet count 137,000. Sodium 139, K
4.1, chloride 110, bicarb 20, BUN 17, creatinine 0.6, blood
sugar 106, PT 14.5, INR 1.5.
Chest x-ray showed widened mediastinum but no significant
infiltrate or effusion. The patient was seen and evaluated by
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], with plan for her possible repair
after cardiac catheterization. Echocardiogram was performed
on hospital day 1. She remained on Labetalol drip at 0.2 and
in sinus rhythm at 85. Her blood pressure was 118/86 on 100%
non-rebreather, 6 liters nasal cell cannula with stable
creatinine of 10, 0.7, K 3.9, white blood cell count 10.8,
hematocrit 42.6, INR 1.3 and lactate of 1.4. She was
comfortable and did have a possible diastolic blowing murmur
as heard at the right upper sternal border. She had radial
line in place. Swan-Ganz was in place. Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **],
continued to monitor her for the possibility of having
cardiac catheterization done prior to surgery, for the
dissection; and a plan for special stent to be made for her
ascending and descending dissection.
On hospital day 2, she had azithro overnight and remained on
labetalol drip at 0.8. She consented for aortic repair with
a special graft stent which needed to be prepared by the
company that manufactured it and continue on her labetalol
drip.
Interventional pulmonology saw her again. Chest x-ray by IP
showed bilateral pleural effusions with some resultant
compressive atelectasis. Interventional pulmonology suspected
the patient had significant shunt through the atelectatic
lung, so they did thoracentesis on the right side and
recommended aggressive pulmonary toilet but no need for
bronch at that time. The patient went into atrial
fibrillation that evening. CT scan showed no pulmonary
embolus. She remained on labetalol drip at 0.5 and back into
sinus rhythm in the morning at a rate of 78 with a good blood
pressure. She was saturating at 92% on 12 liters non-
rebreather. She was comfortable, awake, alert and oriented.
Her lungs were clear bilaterally. She had good pulses. Foley
catheter remained in place. Her left anterior arm had
moderate swelling and ecchymosis. Respiratory status was
unchanged and she continued to be monitored as her aneurysm
was evaluated with dissection in preparation for possible
surgery. Pleural fluid was sent for evaluation by the
interventional pulmonology team.
On the 6th, hospital day 4, she was in sinus rhythm at 72,
her blood pressure was 104/67, well managed on labetalol drip
at 0.4. Her labs were stable. She was alert and oriented. She
remained monitored preoperatively in preparation for
receiving the stent graft that would be needed the following
week to repair her aortic dissection and descending aneurysm.
At 6:30 in the evening of the 6th, the patient suffered a
cardiac arrest while sleeping in bed with acute bradycardia
and hypertension and then asystole in rapid succession.
Blood pressure prior to the event was well controlled with
systolic pressure in the 80's on labetalol with no
hypertensive episode. CPR was unsuccessful. Dr. [**First Name (STitle) **] was
unable to get a rhythm back or good blood pressure in spite
of maximum efforts. Abdominal distension was acute, enlarged
noticed during CPR. Endotracheal tube was in proper position
with a diagnosis of probable acute rupture of her descending
or abdominal aorta causing her arrest. Transthoracic echo was
emergently performed which showed no tamponade. The patient
was pronounced expired at 18:45 p.m. by Dr. [**First Name (STitle) **], and
expired at that time.
DISCHARGE DIAGNOSES:
1. Status post ascending and descending aortic aneurysm with
probable rupture.
2. Hypertension.
3. Hypercholesterolemia.
The patient expired in the cardiothoracic intensive care unit
on [**2118-7-30**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2118-9-9**] 15:32:15
T: [**2118-9-10**] 02:37:10
Job#: [**Job Number 64007**]
ICD9 Codes: 5119, 4275, 5180, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4466
} | Medical Text: Admission Date: [**2179-9-7**] Discharge Date: [**2179-9-13**]
Date of Birth: [**2112-6-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Briefly, this is a 76 year old
female who became short of breath and had dyspnea on
exertion. She was taken to the cardiac catheterization
laboratory where severe two vessel disease was found as well
as a 3+ mitral regurgitation.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Diabetes mellitus with chronic renal insufficiency with
baseline creatinine of 2.1.
3. Hypertension.
4. Anemia.
5. Mild chronic obstructive pulmonary disease.
6. Gastroesophageal reflux disease.
7. Depression.
The patient was taken to the catheterization laboratory and
found to have the severe two vessel disease as well as the
mitral regurgitation.
PHYSICAL EXAMINATION: On physical examination, she was
afebrile and her vital signs were stable. The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Her neck was supple with
no jugular venous distention and no bruits. The lungs had
crackles bilaterally. She had normal expansion. Her heart
was regular rate and rhythm. She had a loud III/VI systolic
murmur best heard in the left upper sternal border. her
abdomen was soft, nontender, nondistended, bowel sounds were
present and extremities were warm and well perfused with no
cyanosis, clubbing or edema.
LABORATORY DATA: White blood cell count was 9.3, hematocrit
36.1, platelet count 243,000. Sodium 140, potassium 4.7,
chloride 105, bicarbonate 21, blood urea nitrogen 36,
creatinine 2.1 and blood sugar 100. Prothrombin time was
12.8, partial thromboplastin time 28.0 and INR was 1.1.
Chest x-ray was within normal limits.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2179-9-7**], where a coronary artery bypass graft times two,
mitral valve replacement and right coronary endarterectomy
were performed. The patient was transferred postoperatively
to the CSRU for care. She was slowly weaned off her
ventilator and due to a metabolic acidosis, it was decided
not to extubate the patient immediately postoperatively. She
was started on Plavix for the RCA endoarterectomy and coumadin
for the mitral valve replacement. The anterior cords were too
attenuated for a mitral repair. The patient was weaned down to
CPAP on postoperative day number one. She continued to do
well. Her chest tubes were removed and that is when Coumadin
was started for prophylaxis for her Mitral valve replacement.
The patient was extubated on [**2179-9-9**], and she continued to
improve. The plavix was discontinued when she was therapeutic
on coumadin. The pain was controlled on p.o. pain medicines
and she was tolerating a regular diet. She continued to be
coumadinized at that time. The patient continued to do well
in the CSRU and was transferred to the floor on [**2179-9-10**].
She continued on her Coumadin and INR was 2.1 and slowly
rising at that time. She was given another 3 mg Coumadin on
[**9-12**]. Her
chest tubes had been removed. Her Foley was
removed at that time as well. Her wires were cut due to the
fact that her INR was elevated and did not want to risk the
chance of bleeding. Physical therapy saw her and she
ambulated and had excellent mobility and good exercise
tolerance. It was felt that she was safe for discharge to
home when medically stable. She continued to do well and on
[**2179-9-11**]. she cleared Stage V with physical therapy,
continued aggressive pulmonary toilet and continued to
anticoagulate her. She was discharged home in stable
condition with goal INR of 2.0 to 3.5.
MEDICATIONS ON DISCHARGE:
1. Lipitor 40 mg p.o. once daily.
2. Percocet one to two tablets p.o. q4hours p.r.n.
3. Coumadin 3 mg p.o. q.h.s. for a goal INR of 2.0 to 3.5.
4. Protonix 40 mg p.o. once daily.
5. Colace 100 mg p.o. twice a day.
6. Zaroxylin.
7. Potassium Chloride 20 meq p.o. twice a day.
8. Lopressor 12.5 mg p.o. twice a day.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
FOLLOW-UP: She was instructed to follow-up with Dr. [**Last Name (STitle) **]
in four weeks and with vascular surgery in two to four weeks
and her primary care physician in [**Name Initial (PRE) **] couple days to have her
INR followed.
DISCHARGE DIAGNOSES:
1. Coronary artery disease and mitral regurgitation, status
post coronary artery bypass graft and mitral valve
replacement.
2. Carotid stenosis, status post right carotid
endarterectomy.
3. Noninsulin dependent diabetes mellitus.
4. Hypertension.
5. Status post myocardial infarction.
6. Chronic renal insufficiency, baseline creatinine 2.1.
7. Congestive heart failure.
8. Depression.
9. Spinal stenosis.
The patient is discharged home in stable condition.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2179-9-11**] 10:21
T: [**2179-9-11**] 11:07
JOB#: [**Job Number **]
ICD9 Codes: 4240, 4280, 496, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4467
} | Medical Text: Admission Date: [**2113-1-30**] Discharge Date: [**2113-2-17**]
Date of Birth: [**2027-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Keflex / Clindamycin / adhesive tape / Gentamicin /
Zosyn / Cefepime
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
N/V/Hypotension/Upper GI bleed
Major Surgical or Invasive Procedure:
Upper endoscopy x 2
intubation/extubation
History of Present Illness:
Ms [**Known lastname 104301**] is a 85 year-old female with hx of dyphagia and
aspiration s/p G-tube placement 1.5 months ago sent in from
[**Known lastname **] to the ED with hypotension, nausea, and vomiting. She
had been in rehab for a month after her G-tube placement until 2
weeks prior to this presentaiton. She presented to [**Known lastname **] on
the day of admission with decreased intake via PEG tube
secondary to nausea. She states she had slightly decreased
intake the day prior to admission, but became extremely nauseous
the day of admission and could not tolerate intake through her
G-tube. She denies abdominal pain, bright red blood in her
stool, or melena.
In the ED, initial VS: BP 75/40. She was guaiac negative on
exam. Surgery was consulted and evaluated her. She was noted
to have bright red blood from the G-tube when it was flushed.
Her Hct was in the mid 20's (from mid to high 30's). GI was
contact[**Name (NI) **] and plan to scope once in the MICU. She was started
on a prontonix gtt. She has two PIVs (20-guage) placed. She
was given 2 L NS and ordered for 1 unit of PRBC. Right as she
was going to be taken up to the MICU, her pressure dropped to a
SBP of 60. She was symptomatic. She was laid flat with
improvement to 79/44. Her unit of PRBC had just been started
when her pressure dropped. She was also nuaseous and was given
some zofran. A third liter of NS was started. Most recent
pressure prior to transport was 91/38.
When the patient arrived in the MICU peripheral levophed was
running. She was maintaining BP in the 90's. She denied pain.
On ROS she denies fevers, chills, dizziness, CP, shortness of
breath, dysuria or other symptoms.
Past Medical History:
Diastolic CHF
Atrial Fibrillation s/p Ablation
Dilated Ascending Aorta
Osteoporosis
Hypothyroidism
Dysphagia for several years with Weight Loss s/p G-tube
placement
History of PNA requiring VATS pleural effusion drainage and
decortication on the right side
Diverticulosis/Diverticulitis
Cerebral Palsy
Macular degeneration
Ventral Hernias
Rosacia
Past Surgical History:
1. Status post removal of bowel obstruction due to
diverticulitis requiring a temporary colostomy
2. Status post surgical repair of a prolapsed uterus
3. Status post total hysterectomy
4. Status post abdominal surgery secondary to complications of
prolapsed uterus surgery - The patient developed multiple
hernias.
5. Status post surgery for exposed keratoses
6. Status post G-tube placement
Social History:
She lives alone in [**Location (un) **]. No tobacco, alcohol, or drug use.
Family History:
non-contributory
Physical Exam:
Initial exam:
GEN: Elderly female laying in bed in NAD. Difficult to
understand.
HEENT: Pupils cloudy, EOMI, anicteric, MM dry, op without
lesions, no jvd
RESP: Breathing comfortably. CTAB.
CV: [**Location (un) 8450**], 3+ systolic murmur heard best at the LUSB.
ABD: +BS, soft, NTND, large ventral hernia present. G-tube
present with bright red blood in the tube with dressing around
it.
EXT: no c/c/e
NEURO: Alert and oriented to person, place, and time. Grossly
nonfocal.
Discharge exam:
General Appearance: extubated, AOx3
Cardiovascular: normal S1/S2, murmur
Respiratory / Chest: clear to auscultation bilaterally
Abdominal: mildly distended, Non-tender, multiple surgical
sites, ventral hernias
Neurologic: answering questions, responding appropriately
Pertinent Results:
Admission Labs:
Na 142 K 4.4 Cl 105 BUN 88 Cr 0.5 Glu 242
.
WBC 10.3 Hct 26.7 Plt 227
N 90.7% L 6.3% M 2.2%
.
PT 15.3 PTT 25.7 INR 1.3
.
Lactate 2.4
.
Hct 26.7 --> 26 --> 25.2 --> 19.1
.
UA neg leuk, neg nitr
.
Micro:
BCx - pending
.
EKG: normal sinus rhythm with 1st degree AV delay. No STE or
STD TWI in 1
Imaging:
CXR: IMPRESSION: No acute intrathoracic process.
KUB: IMPRESSION:
1. No evidence of obstruction.
2. Limited assessment for free air.
EGD [**1-30**]:
Stomach:
Contents: Red blood was seen in the stomach. Large clots
present in fundus below GE junction. PEG site with balloon
[**Month/Year (2) 48613**] without active bleed or [**Month/Year (2) **] from site. Despite
lavage for over two hours unable to clear field for optimal look
at fundus. Potential ulceration on greater curvature but unclear
and no visible vessel or active bleeding from that site. Clot
re-formed after suction given active bleed.
Impression: Blood in the stomach
Blood in the duodenum
Blood in the esophagus
Otherwise normal EGD to second part of the duodenum
EGD [**1-31**]:
Stomach:
Excavated Lesions A single cratered [**Month/Year (2) **] was found in the
fundus just distal to GE junction at the greater curvature
across from the ballon, which appeared to be the source of
bleeding. Dimensions 2cm x 4 cm. No visible vessel or active
bleeding therefore no intervention performed. Small amount of
red blood in stomach. No [**Month/Year (2) **] beneath PEG site.
Duodenum:
Other Small amount of old blood seen in duodenum.
Impression: [**Month/Year (2) **] in the fundus just distal to GE junction
Small amount of old blood seen in duodenum.
Otherwise normal EGD to second part of the duodenum
CXR [**2-17**]: Cardiomediastinal contours are stable in appearance.
Persistent
left lower lobe collapse and adjacent small left pleural
effusion. Linear
atelectasis present at right base with otherwise clear
appearance of right
lung.
Brief Hospital Course:
# Upper GI Blood: Patient has a baseline Hct in the high 30's
(most recently in [**Month (only) **] during her recent hospitalization it
was in the mid 30's). On admission Hct of 26 which was an acute
decline. Guaiac negative on rectal exam, however bright red
blood was noted to come from the G-tube concerning for an upper
GI bleed. She was admitted to the MICU. Prior to admission,
she became hyotensive to the ED requiring levophed. EGD in the
MICU initially showed voluminous bleeding. Her hematocrit
continued to fall to as low as 19. Massive trasnfusion protocol
was activated. The patient received 9 units packed RBCs, 2
units FFP, 1 unit of platelets, and 4 L NS. Her hematocrit
stabilized and levophed was weaned as she was volume
resuscitated. Patient received several units prbcs and GI was
consulted and performed EGD which revealed large clot in the
fundus just distal to GE junction with pulsation seen near the
clot and oozing. PEG site with no evidence of bleeding. She was
initially on a protonix gtt and then transition to PPI [**Hospital1 **] with
planned 8 week course. Overnight on [**2-5**] she was noted to have
hypotension and tachycardia in the context of bright red blood
output per her G-tube. Her HCT dropped from 39 to 31 and she
became tachycardic and hypotensive. In this context she had
altered mental status with confusion and delirium. In the ICU a
subclavian line was placed as peripheral access was lost. The
patient was evaluated by IR, surgery, and GI and sent to the IR
suite for further management. In the IR suite she had
embolization of her left gastric artery, which was bleeding,
leading to her stabilization. She subsequently had a stable hct
with several days of melena but no bright red blood per rectum
or g-tube. She is continued on lansoprazole 30mg [**Hospital1 **]. In total
she required 6U PRBCs, but has not required a transfusion for
over a week at the time of discharge.
# Respiratory Failure: Patient was electively intubated for EGD
because had had difficult EGDs in past. She remained ventilated
for one day and then was extubated on [**2113-2-1**]. However, in the
second admission to the ICU, on [**2-6**] pt was found to have a PEA
arrest requiring rapid reintubation. Pt subsequently had
difficulty with extubation requiring increasing pressure support
and having difficulty producing negative inspiratory force.
Respiratory failure was felt to be [**2-22**] hypervolemia and HAP. HAP
was treated with vancomycin x10d for staph aureus found on
sputum cx. Pt was also diuresed to pre-admission wait. With
improvement of pna and volume status the pt continued to have
difficulty with extubation so neurology was consulted and felt
that her inability to be extubated could be [**2-22**] underlying
chronic dystrophy(possibly [**Last Name (un) 52373**]-scapulo-humeral)which was
exacerbated by neuromuscular blockade from gentamicin. Patient
slowly improved and was subsequently able to be successfully
extubated.
.
# Hypotension: Pt was hypotensive in the setting of GI bleed and
sedation for intubation as above. Pt required pressor support
with Neosynephrine followed by Levophed. Pressors were weaned as
pt stabilized and sedation was weaned. Home blood pressure meds
were held at discharge, and should be restarted at her rehab
facility.
# Chronic diastolic heart failure: Most recent TTE in [**9-29**]
showed EF >70%. Held metoprolol and lisinopril in the setting of
hypotension.
.
# History of atrial fibrillation s/p ablation: Held ASA and
metoprolol in the setting of GI bleed and recent hypotension.
Aspirin will be held at least 2 weeks per GI recs, to be
restarted on [**2-19**].
# Chronic Dysphagia: The patient has chronic dysphagia and
problems clearing secretions. She was started on atropine drops
by mouth to help decrease secretions. Those were subsequently
held and she was continued on tube feeds.
# The patient's hypothyroidism and osteoporosis were stable and
she is discharged on home levothyroxine, boniva, calcium, and
vitamin d.
# Osteoporosis: On Boniva q3 months. Initially held ca/vit d
but restarted once stabilized.
.
# Comm: Daughter, [**Name2 (NI) **] [**Name (NI) 79**] cell: [**Telephone/Fax (1) 104302**]. HCP son [**Name (NI) **].
[**Name2 (NI) 7092**] Status: Full code
Dispo: Pt discharged to [**Hospital 100**] Rehab on [**2113-2-17**].
Medications on Admission:
Levothyroxine 50mcg po by mouth daily
Ferrous Sulfate 220 mg (44 mg Iron)/5ml solution - 7.5 ml po
daily Ranitidine HCl 15 mg/ml syrup - 10 ml by mouth [**Hospital1 **]
Docusate Sodium 60 mg/15mL syrup - 30 mL(s) by mouth [**Hospital1 **]
Calcium carbonate 1250mg daily
Metoprolol 25mg [**Hospital1 **] (no PM dose if systolic <100)
Lisinopril 40mg daily
Diazepam - 1mg daily at bedtime
Senna 8.6 mg tab - 1 tab TID PRN
Aspirin 325mg - 1 tab daily
Vitamin D 500 mg [**Hospital1 **]
Zymar (Gatifloxacin) 0.3% eye drops - Four times/day MWF
Erythromycin ointment - 5mg/gram ointment in her eyes - daily at
bedtime
Bacitracin Zinc Polymycin B Sulfate - 3.5mg ointment po qhs
Boniva q3 months
Multivitamin
Miralax prn
Discharge Medications:
1. erythromycin 5 mg/gram (0.5 %) Ointment [**Hospital1 **]: One (1) drops
Ophthalmic QHS (once a day (at bedtime)): one drop in each eye.
2. bacitracin-polymyxin B 500-10,000 unit/g Ointment [**Hospital1 **]: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)): apply to both
eyes.
3. diazepam 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QHS (once a day (at
bedtime)).
4. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten (10) ML PO Q6H (every
6 hours).
Disp:*1200 ML(s)* Refills:*2*
7. quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS PRN () as
needed for agitation, insomnia.
8. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, headache, fever.
9. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
10. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: Five
(5) ml PO DAILY (Daily).
11. moxifloxacin 0.5 % Drops [**Last Name (STitle) **]: One (1) drop both eyes
Ophthalmic TID (3 times a day) as needed for eye
redness/irritation.
12. atropine 1 % Drops [**Last Name (STitle) **]: One (1) drop Ophthalmic four times a
day as needed for oral secretions.
13. therapeutic multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO
DAILY (Daily).
14. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
15. ascorbic acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ml PO DAILY
(Daily).
16. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization
[**Last Name (STitle) **]: One (1) nebulization Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
17. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1)
nebulization Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
18. Artificial Tears Drops [**Last Name (STitle) **]: 1-2 drops Ophthalmic every
four (4) hours as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Upper GI Bleed secondary to Gastric [**Hospital6 **]
PEA arrest
Hospital Acquired Pneumonia
Secondary:
Hyperlipidemia
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for a large bleed from an
[**Hospital6 **] in your stomach. The GI doctors [**Name5 (PTitle) 48613**] the [**Name5 (PTitle) **] and
confirmed that it was the cause of your bleed, but it had
stopped bleeding. You were treated with a medicine to reduce the
amount of acid in your stomach and help your stomach heal. Your
were transfused blood as your large bleed had caused your blood
levels and blood pressure to get quite low. During your stay,
you had an event where your heart stopped beating, but your
heartbeat returned with medications. You were intubated at that
time to help you breathe. You were diagnosed with a pneumonia,
and received a full course of antibiotics. You were given
medications to help reduce the fluid in your lungs. Your
breathing tube was removed on [**2-16**], and you have done very well
since that time. At the time of discharge your blood levels
were stable, you were breathing well on low levels of oxygen,
and you were tolerating your tube feeds.
.
The following changes were made to your medications:
-You were started on lansoprazole twice per day.
-You were started on seroquel 12.5mg at night as needed to help
you sleep
-Please restart aspirin 325mg daily on [**2113-2-19**]
-You are being given albuterol and ipratropium nebulizers to
help with your breathing as needed.
-You were started on multivitamin, ascorbic acid, and zinc.
-Your blood pressure medications (lisinopril and metoprolol)
were held due to low blood pressures. They will restart these
at your rehab facility once your blood pressures are back to
your baseline.
-The eye medication Zymar was held due to the fact that you were
on multiple eye medications.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2113-2-22**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFUSION/[**Hospital Ward Name 1248**] UNIT
When: THURSDAY [**2113-3-2**] at 10:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Endoscopy appointment: [**2113-4-21**] at 1pm
Please call Dr.[**Name (NI) 104303**] office next week to find out when the
anesthesia appointment will be (usually one week before the
endoscopy appointment).
Completed by:[**2113-2-17**]
ICD9 Codes: 486, 4275, 2760, 2851, 5180, 2767, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4468
} | Medical Text: Admission Date: [**2165-1-11**] Discharge Date: [**2165-1-16**]
Date of Birth: [**2095-2-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Niacin / Zetia / Lopid / Zestril / Benicar / Verapamil
/ Byetta / Avandia / Bactrim
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2165-1-11**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to Ramus, SVG to PDA)
History of Present Illness:
69 y/o female admitted to OSH with palpitations and treated for
SVT, Troponin was 0.82. Underwent cardiac cath which showed
severe coronary artery disease.
Past Medical History:
Hypertension, Hyperlipidemia, Diabetes, TAH, Cataract surgery
left eye, Vitreotomy, Bunion Removal
Social History:
Denies tobacco or ETOH use. Retired.
Family History:
Father died from MI at age 66.
Physical Exam:
VS: 69 18 166/60 5'3" 155lbs.
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB
Heart: RRR -c/r/m/g
Abd: Soft, NT, ND +BS, healed lower abd. incision
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2165-1-14**] CXR: Interval development of moderate hydropneumothorax
in the left lung. No other significant changes.
[**2165-1-14**] Echo: 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 are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is a trivial/physiologic pericardial
effusion.
[**2165-1-11**] Echo: PRE-BYPASS: 1. The left atrium is mildly dilated.
No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. 2. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). 3. Right ventricular
chamber size and free wall motion are normal. 4. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. 5. Trivial mitral regurgitation is seen. A mobile
echogenic structure is noted attached to the posterior mitral
leaflet, flailing into the left atrium in systole possibly a
torn chordae. Some billowing of the A2 scallop is also seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced. 1. Biventricular function is preserved. 2. Aorta
is intact post decannulation. 3. Other findings are unchanged
[**2165-1-10**] 08:40AM BLOOD WBC-9.9 RBC-3.99* Hgb-11.7* Hct-33.4*
MCV-84 MCH-29.3 MCHC-35.0 RDW-12.4 Plt Ct-364
[**2165-1-13**] 02:00AM BLOOD WBC-13.4* RBC-2.84* Hgb-8.5* Hct-24.1*
MCV-85 MCH-30.0 MCHC-35.3* RDW-13.7 Plt Ct-133*
[**2165-1-16**] 04:55AM BLOOD WBC-12.3* RBC-2.57* Hgb-8.4* Hct-24.7*
MCV-96# MCH-32.5* MCHC-33.9 RDW-13.9 Plt Ct-181
[**2165-1-10**] 08:40AM BLOOD PT-11.3 PTT-23.8 INR(PT)-0.9
[**2165-1-14**] 02:23AM BLOOD PT-11.8 PTT-25.3 INR(PT)-1.0
[**2165-1-10**] 08:40AM BLOOD Glucose-146* UreaN-21* Creat-1.0 Na-144
K-4.1 Cl-104 HCO3-31 AnGap-13
[**2165-1-16**] 04:55AM BLOOD Glucose-62* UreaN-19 Creat-0.9 Na-138
K-4.6 Cl-103 HCO3-23 AnGap-17
[**2165-1-16**] 04:55AM BLOOD Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 76309**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**1-11**] she was brought
to the operating room where she underwent a coronary artery
bypass graft x 4. Please see operative report for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Later on operative day
she was weaned from sedation, awoke neurologically intact and
extubated. Post-operatively she required several blood
transfusions secondary to low HCT. On post-op day one she was
started on diuretics and beta blockers. She was gently diuresed
towards her pre-op weight. On post-op day two she had episodes
of atrial fibrillation and was given beta blockers and started
on amiodarone. She converted back to sinus rhythm. On post-op
day three she was transferred to the telemetry floor. Also on
this day her chest tubes were removed with post-pull chest x-ray
showing small bilateral apical pneumothoraces. Chest x-ray also
revealed possible pericardial effusion. On post-op day four
underwent echo which showed only a trivial effusion. She
remained in SR but will continue Amiodarone post-op. She worked
with physical therapy for post-op strength and mobility. On
post-op day five she was discharged to rehab.
Medications on Admission:
Lopressor 25mg [**Hospital1 **], Metformin 1000mg [**Hospital1 **], Diltiazem CD 120mg qd,
Aspirin 81mg qd, Glyburide 5mg [**Hospital1 **], MVI, Fish Oil, Calcium with
Vit. D
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 1 weeks.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 400mg [**Hospital1 **] for 4 days. Then 200mg [**Hospital1 **] for 7
days. And finally, 200mg daily until stopped by cardiologist.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-operative Atrial Fibrillation
PMH: Hypertension, Hyperlipidemia, Diabetes
PSH: TAH, Cataract surgery left eye, Vitreotomy, Bunion Removal
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital 409**] Clinic in 2 weeks on [**Hospital Ward Name 121**] 6
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 7047**] in [**1-13**] weeks
Dr. [**Last Name (STitle) **] in [**12-12**] weeks
Completed by:[**2165-1-16**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4469
} | Medical Text: Admission Date: [**2133-8-5**] Discharge Date: [**2133-8-11**]
Date of Birth: [**2068-7-17**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
cuts to ankles
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 70 year old female with multiple medical issues presented
to the ED with cuts to her legs. There is a question of
self-inflicted wounds vs. assault. At the time of EMS arrival
her door was locked from the inside requiring EMS to force
entry. The patient was found down, responsive, confused, with
no signs of trauma except for the bilateral ankle lacerations,
she was found with large amount of blood on the floor. No
active bleeding at the time of admission. She had week pulses
in the ED initially 40/p then up to 80s with IVF. She was
intubated secondary to nausea/vomiting for airway protection.
She recieved 4 units PRBC and 6 liters IVF, 1 liter LR. She was
given charcoal for presumed toxic ingestion. She was admitted
to the T/SICU intubated on PPF and Dopamine. In the T/SICU she
stabilized. She was weaned off all drips and extubated the
following AM. She was then transferred to the floor.
Past Medical History:
1. HTN
2. hypercholesterolemia
3. CHF
4. Osteoporosis s/p vertebral fractures
5. Depression
6. asthma
7. s/p vaginal CA
8. Herniated disk
9. hx. EtOh abuse
10. s/p MI '[**24**]
11. s/pBilateral leg clots '[**28**]
12, s/p small bowel and stomach resection
13. s/p AAA repair
14. s/p vascular surgery on legs
15. s/p CCK
Social History:
remote history of EtOH, 1ppd smoker for 50 years, lives alone
Family History:
non-contributory
Physical Exam:
Temp 97.9
BP 74
Pulse 135/59
Resp 13
O2 sat 97% on RA
Gen - Alert, no acute distress
HEENT - PERRL, bilateral cataracts, extraocular motions intact,
anicteric, mucous membranes moist
Neck - right IJ line, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - Bilateral ankle lacerations, dressings clean dry and
intact, No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-12**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
[**2133-8-5**] 06:55PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2133-8-5**] 06:40PM WBC-9.5 RBC-3.15* HGB-11.2* HCT-32.2*
MCV-102* MCH-35.5* MCHC-34.8 RDW-14.5
[**2133-8-5**] 10:49PM GLUCOSE-162* LACTATE-3.3* NA+-142 K+-4.1
CL--115*
Brief Hospital Course:
Please see addendum for additional hospital course.
1. Ankle lacerations - She was evaluated by ortho who advised
that she received a tetanus shot and that the wounds not be
closed when she first arrived. On the third day of
hospitalization they advised to have the trauma team suture the
wounds.
2. Increased LFTS - After she was transferred out of the MICU
her LFTs were elevated. These appeared to be due to shock liver
due to her severe fluid loss from bleeding. When rechecked
later they had normalized.
3. CV - Upon tranfer to the floor she was noted to have
crackles throughout her lungs and be SOB. She had been given a
lot of fluid the prior day. It was felt that she was in mild
CHF and she was given 20mg Lasix IV with good effect.
4. Pulmonary - She was noted to be SOB upon transfer to the
floor. We restarted all of her home asthma medications and
inhalers with good effect.
5. Psychiatry - The psychiatry team evaluated her while she was
in the MICU and again on the floor. They initially felt that it
was most likely these wounds were due to assault and not self
inflicted. However, upon obtaining the police report and with
careful patient questioning, it appeared that the wounds were in
fact self-inflicted. She will be admitted to a psychiatric
facility.
6. Her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], was contact[**Name (NI) **] and all
of her out-patient medications were restarted.
Medications on Admission:
Meclizine prn
Ezetimibe 10
Rofecoxib 25
Theophylline SR 300 TID
Cardiazem CD 360
Fluoxetine 20
Lasix 40
Atenolol 25 [**Hospital1 **]
Advair
Albuterol
Xanax prn
Protonix 40
Trazadone 150
MVI
Synthroid 25
Discharge Medications:
see addendum
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1680**] HRI
Discharge Diagnosis:
see addendum
Discharge Condition:
see addendum
ICD9 Codes: 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4470
} | Medical Text: Admission Date: [**2126-8-6**] Discharge Date: [**2126-8-11**]
Date of Birth: [**2050-2-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Claudication and ischemic rest pain of the left foot with
failing left femoral-popliteal bypass.
Major Surgical or Invasive Procedure:
[**2126-8-6**]- Selective left lower extremity arteriography with
angioplasty and stenting of the distal left external iliac
artery, angioplasty of an in-stent restenosis of a previously
placed distal superficial femoral artery/popliteal artery stent,
and angioplasty of the left anterior tibial artery.
History of Present Illness:
The patient is a 76 year old female with known peripheral
vascular disease who has had 2 previous lower extremity bypass
grafts in [**2122**] and [**2125**], who has develpoed an infected ingrown
toenail on her left foot, which has since healed, as well as a
prolonged period of a non-healing ulcer on the left foot, which
has also since healed.
Past Medical History:
2 left lower extremity bypass grafts ([**2121**], [**2125**]), hypertension,
hypercholesterolemia, bilateral carotid endarterectomies, and a
cholecystectomy
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
General: no acute distress
Lungs: Clear to ascultation bilaterally
Cardiac: regular rate and rhythum
Abdomen: soft, nontender, nondistended
Extremities: no clubbing, cyanosis, or edema
Pulses: 1+ femorals bilaterally, no distal pulses palpable on
the left lower extremity.
Neuro: alert and oriented X3
Pertinent Results:
[**2126-8-11**] 05:35AM BLOOD WBC-7.2 RBC-3.42* Hgb-9.6* Hct-29.6*
MCV-86 MCH-27.9 MCHC-32.3 RDW-15.1 Plt Ct-219
[**2126-8-11**] 05:35AM BLOOD Plt Ct-219
[**2126-8-10**] 05:45AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-140
K-4.0 Cl-109* HCO3-24 AnGap-11
[**2126-8-10**] 05:45AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.3
Brief Hospital Course:
The patient is a 76 year old female who was admitted on [**2126-8-6**]
for claudication and rest pain of her left foot due to a failing
graft. The plan at that time was for angioplasty that day and
discharge on [**2126-8-7**]. However, on the night of [**8-6**] the patient
developed a retroperitoneal hematoma and a rectus sheath
hematoma (as diagnosed by ultrasound) after her sheath was
pulled. As a result, she developed severe abdominal and back
pain, became extremely lethargic and babbling, was AXOX1, with a
blood pressure of 72/50, heart rate in the 70s, respiratory rate
16-22, and oxygen saturation > 95%. Her hematocrit dropped from
35.4 to 31.8 during over the course of the day.
She was then transferred to the ICU on the morning of [**2126-8-7**] in
stable condition, with a plan of serial hematocrit checks, BP
and groin checks, and morphine as needed for pain.
On [**2126-8-8**], the patient was doing much better- her hematocrit
was stable at 29, her abdomen was softer, there was no evidence
of an MI, and she had excellent distal pulses. Her Plavix was
held and she was able to resume diet. Later that day she was
transferred to the VICU.
On [**2126-8-10**], she was transfused one unit of packed red blood cells
for a hematocrit of 25.6. Her hematocrit stabilized thereafter
and the rest of her hospital course was uncomplicated.
Medications on Admission:
See discharge medications
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT
RESUME TAKING UNTIL YOUR BLOOD COUNTS ARE CHECKED BY YOUR PMD!.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vascular disease of the left lower extremity
Discharge Condition:
Stable.
Discharge Instructions:
1) Return to ER or call Dr.[**Name (NI) 5695**] office if you notice
increasing pain or drainage from your groin, or if you become
excessively weak or short of breath.
2) For now continue taking aspirin but do not take plavix. Have
your blood count checked by the end of this week (by [**2126-8-16**]) by
your PMD, and if stable (i.e. > 28), you may begin taking Plavix
at the usual dose (75 mg PO qday).
Followup Instructions:
Call Dr.[**Name (NI) 5695**] office on [**2126-8-19**]: [**Telephone/Fax (1) 3121**].
Completed by:[**2126-8-12**]
ICD9 Codes: 2851, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4471
} | Medical Text: Admission Date: [**2112-10-7**] Discharge Date: [**2112-10-17**]
Date of Birth: [**2039-8-6**] Sex: M
Service: UROLOGY
HISTORY OF THE PRESENT ILLNESS: This is a 73-year-old male
with refractory CIS of the bladder treated by Dr. [**Last Name (STitle) 986**]
since [**2106**]. He has been treated with intravesical BCG as
well as BCG and Interferon and his most recent bladder biopsy
demonstrates persistent multifocal CIS. Options were
discussed and he decided to proceed with cystoprostatectomy
by Dr. [**Last Name (STitle) 986**] to be followed by ileal loop urinary
diversion by Dr. [**Last Name (STitle) 4229**].
On examination, his abdomen was soft, nontender,
nondistended, and obese.
LABORATORY/RADIOLOGIC DATA: Preoperative laboratories showed
a BUN and creatinine of 40/1.6, hematocrit of 35, and a
urinalysis with 135 red blood cells per high-powered field.
The PSA was 0.3. The patient had a preoperative stress test
which showed no evidence of myocardial ischemia. His
echocardiogram showed a left ventricular ejection fraction
greater than 55%. He had mild to moderate aortic
regurgitation and mild mitral regurgitation.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2112-10-7**]. Please see the operative dictation for details
of that procedure. He was monitored by a Swan-Ganz catheter.
He received 9.5 liters of crystalloid and 2 units of packed
red blood cells. The EBL was estimated at 600. He underwent
a radical cystoprostatectomy with ileal loop urinary
diversion as well as bilateral pelvic lymph node dissection.
Two JPs were left in place as well as bilateral ureteral
stents. However, on KUB, the left stent was shown to be
malpositioned and likely in the ileal loop. This was thus
removed.
Mr. [**Known lastname **] had significant output by both JPs, however,
greater in the right JP than the left JP. This was
especially high approximately one week postprocedure when the
ostomy output dropped to zero and the right JP output was
subsequently approximately 2,500. A Foley catheter was
placed in the ostomy to use as a stent. It was likely that
the obstruction in part was due to the ostomy appliance
material. The JP output subsequently decreased; however, was
still putting out on the order of close to 1,000 a day.
A CT urogram was obtained on postoperative day number six
which showed no ureteral leak. The Foley catheter was thus
removed; however, it was again noted that the ostomy output
was decreasing so this was replaced again. The right JP
output remained persistently high. It looked to be the color
and consistency of urine. The suction drainage was then
switched over to a gravity drainage. Creatinine of both
drains in the ostomy showed the creatinine of the ostomy to
be 70, the creatinine of the right drain 39 and the
creatinine of the left JP to be 1.1. The left JP was
subsequently removed on postoperative day number nine and the
patient will be discharged to rehabilitation with the Foley
catheter in the stent opening the ostomy as well as the right
drain to gravity drainage.
1. NEUROLOGY: The patient's pain was controlled with
epidural. However, after he was extubated, he was noted to
be rather somnolent. The epidural was titrated down due to
this and eventually was discontinued on postoperative day
number five. At this point, he was switched over to a PCA.
He was noted to be somewhat more alert after the epidural was
discontinued. The patient also complained of some right leg
weakness. This was initially presumed to be due to epidural
placement. It slowly improved with physical therapy.
2. CARDIOVASCULAR: The patient had a rule out MI protocol
immediately postoperatively which showed elevated CKs up to
6,000; however, his CK MB was 22 for an MB index of 0.4. In
addition, his troponin was 0.03 or less. Lopressor and
Hydralazine were used to control his blood pressure. He was
initially monitored with a Swan-Ganz catheter which was
eventually switched to a CVL on postoperative day number two.
He was kept on telemetry for monitoring.
On postoperative day number eight, he experienced
postprandial epigastric discomfort which resolved with Tums;
however, given his significant cardiac history and diabetic
history, a second rule out MI protocol was performed which
showed nonspecific T wave inversions in V1 through V3;
however, his enzymes were negative. He was eventually
switched over to his home regimen which controlled his
hypertension.
3. PULMONARY: The patient was extubated on postoperative
day number two. He was weaned from his oxygen without
issues.
4. GASTROINTESTINAL: Postoperatively, the patient was
maintained with a NG tube and IV Pepcid. The NG tube was
self-discontinued on postoperative day number four. Sips
were begun on postoperative day number seven and his diet was
advanced without difficulty. As stated under cardiac, the
patient experienced epigastric discomfort on postoperative
day number eight. This resolved with Tums and for this
reason, the patient is maintained on p.o. Pepcid.
5. GENITOURINARY: Please see the main hospital course for
details on his ostomy and drain functions. At this point, a
loopogram will be obtained prior to discharge to evaluate for
ureteral leak. The results of this will be dictated in a
separate note.
6. HEME: The patient was maintained on Lovenox 40 mg b.i.d.
for DVT prophylaxis. He again started complaining of right
lower extremity pain on postoperative day number nine. He
had a slight increase in leg swelling, 1+ pedal edema on the
right compared to none on the left. His pain was diffuse
including his anterior and posterior leg as well as his
thigh. He reported having a history of right lower extremity
pain as well as some asymmetrical swelling ever since back
surgery many years ago. Although the clinical suspicion for
DVT was low, LENIs were obtained on the date of discharge.
The results of these will be dictated in an addendum.
7. INFECTIOUS DISEASE: The patient was given perioperative
Ancef
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38941**]
Dictated By:[**Name8 (MD) 99739**]
MEDQUIST36
D: [**2112-10-17**] 12:45
T: [**2112-10-17**] 12:51
JOB#: [**Job Number 99740**]
cc:[**Last Name (NamePattern4) **]
ICD9 Codes: 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4472
} | Medical Text: Admission Date: [**2131-1-3**] Discharge Date: [**2131-1-7**]
Date of Birth: [**2131-1-3**] Sex: M
Service: NB
REPORT TITLE: Interim summary
HISTORY: The patient was delivered at 40-5/7 weeks'
gestation, and was admitted to the newborn intensive care
unit around four hours of life, for evaluation and treatment
of poor tone and perfusion. Birth weight was 2955 gm.
Mother is a 25-year-old, gravida 1 mother, with estimated
date of delivery [**2130-12-29**]. Her prenatal screens included
blood type B-positive, antibody screen negative, hepatitis B
surface antigen negative, rubella immune, RPR nonreactive,
and group B strep negative. The pregnancy was uncomplicated.
Labor and delivery were uncomplicated. Amniotic fluid was
noted to be clear. The infant delivered by spontaneous
vaginal delivery. Apgar scores were 8 and 8, at one and five
minutes, respectively.
Initial bedside glucose testing showed a blood glucose of 42.
The infant was fed [**1-3**] ounce and initially did well. At
around four hours of age, noted to have decreased tone and
ashen color in the newborn nursery. He also was noted to
have a 1/7 systolic ejection murmur at the left sternal
border.
PHYSICAL EXAMINATION: At discharge, an active and alert,
sucking on pacifier in crib. Pale pink, with mild jaundice.
Anterior fontanelle open, flat, soft. Mild molding and
overriding of features. Ears, eyes, nose, and throat are
unremarkable. Breath sounds are clear and equal, with easy
work of breathing. Heart rate regular, with normal S1 and
S2. Has a soft systolic ejection murmur noted along the left
sternal border. Has normal, equal pulses. Well-perfused.
Abdomen is soft and nondistended, with no hepatosplenomegaly.
Active bowel sounds. Umbilical cord dry. Normal phallus.
Testes descended bilaterally. Spine straight and intact; no
dimples. Has mongolian spots on both buttocks. Hips are
stable. Normal tone and reflexes. Discharge weight is 2980
gm (25th to 50th percentile), length 49 cm (50th percentile),
head circumference 33 cm (25th to 50th percentile).
SUMMARY OF HOSPITAL COURSE: Respiratory: He was placed
nasal cannula oxygen on admission to maintain oxygen
saturation greater than 95%. Initially required 250 cc/min
flow of oxygen. Initial chest x-ray showed patchy
atelectasis in the left upper lobe and a trace amount of
fluid in the minor fissure. The infant was weaned off oxygen
on [**2131-1-4**], at around 1400. He has been greater than 24
hours on room air, with comfortable work of breathing,
respiratory rates in the 30s to 60s.
Cardiovascular: A soft murmur noted on exam on admission,
due to poor perfusion. A hypoxia test was performed, with
arterial blood gases showing pH of 7.45, pACO2 37, pAO2 254.
He has remained hemodynamically stable throughout the
intensive care stay. Recent blood pressure was 61/40, with a
mean of 52. Heart rate range is 110s to 140s. Have been
following the murmur clinically.
Fluids, electrolytes, nutrition: Initial he was n.p.o. As
feeds were started on day of life #1 with Enfamil 20 calorie
or breast milk if available. He is feeding well, voiding and
stooling appropriately. Discharge weight is 2980 gm.
Gastrointestinal: Bilirubin on day of life 2: Total 6.5,
direct 0.3. A follow up bilirubin will be done on
[**2131-1-6**].
Hematology: Hematocrit on admission was 48%.
Infectious disease: CBC and blood cultures were drawn on
admission, and he was started on ampicillin and gentamicin.
White count was 15.9, with 65 polys, 1 band, platelets
237,000. An LP was done the following day, after the baby
was on antibiotics. Initial results showed a WBC of 6, RBCs
8, with 2% polys, protein 116, glucose 52. The culture is
pending. The decision was made to treat for seven days for
suspected sepsis. Gentamicin level is pending around third
dose.
Neurology: Initially with low tone, which has improved.
Hearing screening has not been performed; will need prior to
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to newborn nursery.
PRIMARY PEDIATRICIAN: [**Hospital1 **] in
[**Location (un) 686**], MA ([**Telephone/Fax (1) 7976**]).
CARE AND RECOMMENDATIONS:
1. Feedings: Ad lib breast or bottle feeding.
2. Medications: To be seven days of ampicillin and
gentamicin to be completed prior to discharge home.
Check gentamicin levels around third dose. Iron
supplementation is recommended for preterm and low-birth
weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
vitamin D supplementation at 200 IU, which may be
provided as a multivitamin preparation daily until 12
months corrected age.
3. State newborn screen to be drawn on [**2131-1-6**].
4. Immunizations: Has not received any immunizations yet.
5. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**]. The infant may meet the
following four criteria:
I. Born at less than 32 weeks.
II.Born between 32 and 35-0/7 weeks with two of the
following: Day care during RSV season or a
smoker in the household, neuromuscular disease,
airway abnormalities or school-age siblings.
III. Chronic lung disease.
IV.Hemodynamically significant congenital heart
disease.
b. Influenza immunization is recommended annually in
the fall, for all infants once they reach six months of
age, before this age, and for the first 24 months of
the child's life, immunization against influenza is
recommended for household contacts or out-of-home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital, if they are clinically
stable and are at least six weeks but fewer than 12
weeks of age.
6. Follow up appointments: Follow up with pediatrician
following discharge.
DISCHARGE DIAGNOSES:
1. Appropriate-for-gestational-age term male.
2. Respiratory distress, resolved.
3. Heart murmur.
4. Suspected sepsis.
5. Physiologic jaundice.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2131-1-5**] 23:09:48
T: [**2131-1-6**] 03:25:49
Job#: [**Job Number 77078**]
ICD9 Codes: 769, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4473
} | Medical Text: Admission Date: [**2135-2-10**] Discharge Date: [**2135-2-11**]
Date of Birth: [**2083-5-26**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 51-year-old male
patient with a previous history of coronary artery disease
evidenced by a previous myocardial infarction in the [**2112**].
He had approximately a one week history of vague chest pain
and on the morning of [**2135-2-10**] had severe chest pain
with diaphoresis while working that morning and called
emergency medical services. He was transported by ambulance
to [**Hospital3 417**] Hospital where he was held in their
Emergency Department with continued complaints of chest pain
with diaphoresis, although his vital signs were stable during
this stay there and his first set of cardiac enzymes was
negative. Because the patient continued to have unstable
angina while in the Emergency Department, he was ultimately
transported later in the day from the [**Hospital3 417**]
Emergency Room to [**Hospital6 256**] for
cardiac catheterization.
PAST MEDICAL HISTORY: Significant for a fairly recently
diagnosed type 2 diabetes mellitus, hypertension,
hyperlipidemia, obesity. The patient is a current cigarette
smoker, approximately 2 packs a day x 30 years, and alcohol
intake is not obtainable at this time.
SOCIAL HISTORY: The patient works as a truck driver, he is
not married, and he lives in [**Location 12366**].
The patient was transported from [**Hospital3 417**] Hospital to
[**Hospital6 256**] late afternoon on
[**2135-2-10**] and was taken directly to the Cardiac
Catheterization Lab to undergo cardiac catheterization. In
the Cardiac Catheterization Lab, the patient suffered a
cardiopulmonary arrest; please see Cardiac Catheterization
Lab records, as well as resuscitation paperwork for details
of arrest and resuscitation. This occurred at 5:45 pm with
precipitating issue of profound hypotension to a systolic
pressure of 60. Initial heart rhythm at that time was sinus
tachycardia with a rate of about 120. Over the next 15
minutes, the cardiac rhythm deteriorated to a ventricular
tachycardia, ventricular fibrillation. He was defibrillated
and became asystolic approximately 10 minutes into the
resuscitation. CPR was initiated at the onset of
pulselessness and was continued throughout the arrest
situation. While in the Cardiac Catheterization Lab, femoral
arterial and venous cannulation was obtained and the patient
was placed on cardiopulmonary bypass in the Catheterization
Lab and transported directly from the Cath Lab to the
operating room. Cardiac catheterization results available
revealed 100% proximal and thrombotic LAD occlusion,
nondominant severely diffuse diseased left circ, and a 100%
ostial occlusion of the right coronary artery.
In the operating room, the patient underwent coronary artery
bypass graft x 3 by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and insertion of
bilateral ventricular assist devices, the Abiomed BVS system.
Intraoperatively, there was some difficulty removing the
cannulas which were placed emergently in the Catheterization
Lab requiring consultation of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], vascular
surgeon, to assist with removal of cannulas. An intra-aortic
balloon pump had been inserted at the initial onset of
hemodynamic instability in the Cardiac Catheterization Lab.
Postoperatively, the patient was transported from the
operating room to the Cardiac Surgery Recovery Unit at
approximately 4:00 am. During the postoperative period, the
patient had some requirement for blood products due to some
hypovolemia and dropping hematocrit. There was no excessive
chest tube bleeding during this time. The patient's
coagulation parameters were within normal limits, as were his
other laboratory values. Postoperative chest x-ray revealed
a right-sided pleural effusion for which he had a right
pleural chest tube placed in the Intensive Care Unit. A
Swan-Ganz catheter was malpositioned and subsequently
removed. His left femoral intra-aortic balloon pump was
removed shortly after admission to the Cardiac Surgery
Recovery Unit. The patient has been accepted for evaluation
for heart transplant at [**Hospital 4415**] by Dr.
[**Last Name (STitle) **] and the patient is ready to be transported to [**Hospital 14852**] at this time.
The patient's physical condition is as follows:
Neurologically, the patient has woken up. Preoperatively, he
has moved all four extremities to command and nodded his head
appropriately. He has since been paralyzed with
cisatracurium and sedated with IV propofol drip. Cardiac
wise, the patient is in sinus tachycardia heart rhythm with
rare PVC noted. He has a left ventricular Abiomed
ventricular assist device, as well as right ventricular
assist device in place. Both ventricular devices have flows
of approximately 4.5-5 L/min. The patient has an open chest,
open sternum, open skin with an Esmarch dressing. He has two
mediastinal chest tubes. He has a right pleural chest tube,
both to Pleur-Evac suction. His lungs have a few scattered
rhonchi bilaterally but are fairly clear. His abdomen is
obese but soft. His left lower extremity has an incision
from a saphenous vein harvest site. His right groin has an
incision from his cannulation, as well as repair by vascular
surgery service. The patient has positive Doppler signals in
his feet and has had adequate urine output throughout.
Most recent laboratory values are from 7 o'clock this
morning, [**2-11**], which revealed a white blood cell count of
5.8, hematocrit 22.7 for which he received a total of 3 units
of packed red blood cells--his hematocrit after the second
unit of cells came up to 29, platelet count 115,000,
prothrombin time 13.1, with an INR of 1.2, PTT 40.5,
fibrinogen level 231, sodium 144, potassium 3.1, chloride
105, CO2 23, BUN 15, creatinine 1.1, glucose 236. The
patient's ALT is 86, AST 534, alk phos 42, total bilirubin
1.5, albumin 2.7, calcium 9.8, phosphate 2.2, magnesium 1.2.
The patient has had HIV panel sent and pending, as well as
hepatitis A, hepatitis B, hepatitis C full panels also
pending. Most recent blood gas was 7.40, PCO2 37, PO2 118
and bicarb of 24. The patient had a lactate level of 11.3 at
4 o'clock this morning.
The patient's most recent vital signs revealed a temperature
of 96.1, heart rate 109, sinus tachycardia, blood pressure
97/66, right ventricular assist flow of 4.7 L/min and left
ventricular assist flow of 4.1. The patient is on amiodarone
drip at 1 mg/min, epinephrine at 0.1 mcg/kg/min, heparin at
500 U/hr, insulin at 30 U/hr, Levophed at 0.04 mcg/kg/min,
propofol at 20 mcg/kg/min and cisatracurium at 1 mcg/kg/min.
Current ventilator settings are assist control with a rate of
12, tidal volume of 800 cc, FIO2 40% and 15 of PEEP with a
blood gas of 7.40, 37, 118, 24 with subsequent decrease in
PEEP to 10. Urine output has been adequate. Chest tube
output has been minimal.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2135-2-11**] 11:01
T: [**2135-2-11**] 10:43
JOB#: [**Job Number 38623**]
ICD9 Codes: 4275, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4474
} | Medical Text: Admission Date: [**2104-6-8**] Discharge Date: [**2104-6-17**]
Date of Birth: [**2041-10-15**] Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
MRCP
Quadricep Muscle Biopsy
History of Present Illness:
62 yo f w/PMH of hypercholesterolemia, CABGx4, HTN that presents
w/ progressive myalgia of bilateral shoulders, triceps &
quadriceps. On the morning of [**2104-6-8**], pt felt weak, used hands
to raise from bed and once had reached her toilet could not
stand up. Needed assistance to get up from toilet & decided to
go to ED. Pt feels decr ROM in shoulder abduction & quadricep
extension, feels legs "weigh 100lbs", and weakness that has been
progressively gotten worse since she began on Atorvastatin
post-op. Her PMH is significant for CABGx4 on [**2104-3-5**]. Pt
complains of malodorous breath, nauseated after eating w/some
vomit, itchiness of scalp, forearm & feet. Pertinent neg: (-)
rebound tenderness, (-)TTP, no RUQ pain on inspiration,(-)
fever, no mental status changes, no palmary erythema; no rashes,
lumps, skin dryness, dermal color changes; no headache,
dizzyness, lightheadness; no hematurea, polyurea, oliguria,
dysurea; no diarrhea, constipation, stool color changes.
In the ED @833a, pt's VS:T 97.2 BP 122/75 HR 74 RR 18 O2 sat
100% pain [**8-18**]. EKG showed no ST wave changes, nl axis, nl
interval , nl sinus rhythm w/reg rate @60bpm. Liver/gallbladder
u-sound showed no signs of cholecystitis & no R kidney, L kidney
was 14cm. U/A significant for hematurea & slight proteinurea 30.
Notable labs include elevated LFTs: ALT 578, AST 1354, AP 1113,
Tbil 5.6, Dbili 4.4; elevated lipsase 350; elevated CK 22,215;
hyponatremia 128, hyperphosphatemia 5.2, hypomagnesiemia 2.7;
elevated BUN 52 & creat 3.1. Incr WBC 11.4 w/L-shift. Incr
sed-rate @ 45. Folate catheter placed. Received 1L 150cc/hr nl
saline, 1L D5W w/NaHCO3 150mEq.
In the floor, pt's VS: T 98.3 BP 120/60 Pulse 88 RR 20 97%O2sat
w/pain 0/10. On PE, pt still felt pain near the spinal scapula
bilaterally w/decr ROM when abducting, had quadricep flexion
weakness yet nl sensory function. Nl MSE & cognitive assesment.
Pt had scleral icterus, nl abdomen w/high pitch high frequency
bowel sounds, unpalpable liver & splenic borders.
Past Medical History:
-CABGx4 repair: On [**2104-3-1**] pt presents to [**Last Name (un) 1724**] w/ substernal
chest pain; cath lab showed severe occlusion of obtuse marginal,
LAD septal branch, LAD diagonal & L circumflex arteries. CABG
repair done using saphenous v & internal mammary arteries.
Received 2 u of packed RBCs. Discharged w/Atorvastatin.
-Hypercholesterolemia: Currently controlled w/atorvastatin
-HTN: Controlled w/Lisinopril/Metropolol.
Social History:
Works at for Partner's in [**Hospital1 **] Occupational Health [**Doctor Last Name **]
Division. Lives alone at home, but has male partner who visits.
No EtOH hx. Smoked 4 cigarettes/day from young age until
[**2104-3-4**].
Family History:
Mother suffered from angina & died @70; father died @ 57 from
CHF & was EtOH abuser. Two maternal uncles who had an MI at the
age of 42, and one at the age of 60. Older brother has DM, 2
cardiac stents. Sister dx w/breast cancer in her 40s
Physical Exam:
VS: T 98.3 BP 120/60 Pulse 88 RR 20 97%O2sat
GEN: Well-appearing female in NAD
HEENT: NC/AT, no LAD, +scleral icterus bilaterally
NEURO: PERRL, EOMI; V, VII-XII intact
MSE: Oriented to time, place, location; nl immediate & lag
recall of 3 words, draws clock hand w/slight hand deviation.
ABDOMEN: non-distended abdomen w/o surgical scars, high pitch
high freq bowel sounds, no TTP, no rebound tenderness,
unpalpable liver & spleen, no renal/epigastric bruits. No
[**Doctor Last Name **] sign. Nl percussion of abdomen w/o signs of ascites.
CARDIO: nl S1 S2 yet loud, slight tachycardia, no m/g/r
RESP: CTAB, no CVA, nl percussion from apex to base, tender
bilaterally near the spinal scapula, non-tender spine.
MUSK: UE: nl motor strength. L LE: weak hamstring 3+, weak
quadricep 3+, weak abduction 4+, otherwise normal; R LE: weak
hamstring 4+, weak quadricep 4+; other wise normal.
SKIN: No rashes, lumps, bumps.
EXTREMITIES: No signs of peripheral edema
PSYCH: Affable & responsive; reliable historian
Pertinent Results:
Admission labs:
[**2104-6-8**] 07:50PM GLUCOSE-104 UREA N-48* CREAT-2.7* SODIUM-143
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-18* ANION GAP-17
[**2104-6-8**] 07:50PM ALT(SGPT)-450* AST(SGOT)-1087* CK(CPK)-[**Numeric Identifier 61415**]*
ALK PHOS-806* TOT BILI-3.9*
[**2104-6-8**] 07:50PM PT-13.9* PTT-28.5 INR(PT)-1.2*
[**2104-6-8**] 11:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-6-8**] 11:35AM URINE RBC-[**3-13**]* WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0
[**2104-6-8**] 09:00AM GLUCOSE-131* UREA N-52* CREAT-3.1*#
SODIUM-128* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-16* ANION
GAP-21*
[**2104-6-8**] 09:00AM ALT(SGPT)-578* AST(SGOT)-1354* CK(CPK)-[**Numeric Identifier 61416**]*
ALK PHOS-1113* AMYLASE-227* TOT BILI-5.6* DIR BILI-4.4* INDIR
BIL-1.2
[**2104-6-8**] 09:00AM LIPASE-350* GGT-528*
[**2104-6-8**] 09:00AM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-5.2*
MAGNESIUM-2.7*
[**2104-6-8**] 09:00AM TSH-0.39
[**2104-6-8**] 09:00AM WBC-11.4* RBC-4.80 HGB-14.3 HCT-43.1 MCV-90
MCH-29.9 MCHC-33.3 RDW-15.6*
[**2104-6-8**] 09:00AM NEUTS-86.7* LYMPHS-8.3* MONOS-4.0 EOS-0.8
BASOS-0.4
[**2104-6-8**] 09:00AM PLT COUNT-323
[**2104-6-8**] 09:00AM SED RATE-45*
.
Liver/Gall bladder ([**2104-6-8**]): 1. Two small hemangiomas in the
liver.
2. Gallstone with no ultrasound evidence of cholecystitis.
3. Right kidney not seen; could be agenesis or ectopic kidney.
Left kidney
measures 14 cm.
.
MRCP ([**2104-6-8**]): 1. No biliary obstruction. Normal-appearing
intra- and extra-hepatic biliary ducts. 2. Pancreas divisum. The
pancreas demonstrates a normal signal without ductal dilatation.
3. Solitary left kidney, with edema and loss of corticomedullary
differentiation, as seen in acute renal failure. No
hydronephrosis. 4. Edema in the musculature of the flanks and
paraspinal muscles, consistent with the history of recent
rhabdomyolysis.
.
Muscle Biopsy Right Thigh ([**2104-6-14**]): pathology pending
.
INR Trend:
[**6-8**] 1.2
[**6-10**] 2.2
[**6-11**] 1.7
[**6-12**] 2.1
[**6-13**] 2.0
[**6-14**] 3.4
[**6-14**] 5.8
[**6-15**] 1.1
[**6-16**] 1.0
[**6-17**] 1.0
.
Creat Trend:
[**6-8**] 3.1
[**6-8**] 2.7
[**6-9**] 2.7
[**6-10**] 2.2
[**6-11**] 1.9
[**6-12**] 1.7
[**6-13**] 1.5
[**6-14**] 1.2
[**6-15**] 1.1
[**6-16**] 1.0
[**6-17**] 1.0
.
CK Trend:
[**6-8**] [**Numeric Identifier 61416**]
[**6-8**] [**Numeric Identifier 61415**]
[**6-9**] [**Numeric Identifier **]
[**6-10**] [**Numeric Identifier **]
[**6-11**] [**Numeric Identifier 61417**]
[**6-12**] [**Numeric Identifier 21712**]
[**6-13**] [**Numeric Identifier 24508**]
[**6-14**] [**Numeric Identifier 61418**]
[**6-15**] [**Numeric Identifier 61419**]
[**6-16**] [**Numeric Identifier 61420**]
[**6-17**] 6784
.
HBsAg NEGATIVE
HBsAb BOREDERLINE
HBcAb NEGATIVE
HAV NEGATIVE
HCV NEGATIVE
AMA NEGATIVE
Smooth NEGATIVE
[**Doctor First Name **] NEGATIVE
SPEP Pending
Acetaminophen NEG
ALPHA-1-ANTITRYPSIN PND
CERULOPLASMIN PND
IGG HERPES SIMPLEX VIRUS 1 AND 2 PND
IGM HERPES SIMPLEX VIRUS 1 AND 2 PND
SOLUBLE LIVER ANTIGEN (SLA) ANTIBODIES PND
.
Discharge labs:
[**2104-6-17**] 05:34AM BLOOD WBC-8.5 RBC-3.21* Hgb-9.5* Hct-27.9*
MCV-87 MCH-29.6 MCHC-34.1 RDW-16.2* Plt Ct-286
[**2104-6-15**] 04:50PM BLOOD Neuts-78.8* Lymphs-15.0* Monos-3.7
Eos-1.8 Baso-0.6
[**2104-6-17**] 05:34AM BLOOD PT-11.6 INR(PT)-1.0
[**2104-6-17**] 05:34AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-138
K-2.9* Cl-99 HCO3-34* AnGap-8
[**2104-6-17**] 05:34AM BLOOD ALT-685* AST-758* CK(CPK)-6784*
AlkPhos-647* TotBili-2.6*
[**2104-6-17**] 05:34AM BLOOD Albumin-2.1*
Brief Hospital Course:
#. Acute Hepatic Dysfunction: On admission patient had ALT 578,
AST 1354, ALP 1113, T-BIL 5.6, D-BIL 4.4, Lipase 350, Amylase
227. Patient had scleral icterus and malodorous breath; no
visible signs of encephalopathy, no hepatosplenomegaly and no
abdominal tenderness. Extrahepatic causes ruled out from normal
MRCP & abodminal ultrasound that failed to show biliary tract
dilation and obstruction. Intrahepatic causes were ruled out
including viral hepatitis (negative Hep A, Hep B & C serologies)
& autoimmune hepatitis (anti-smooth, anti-mitochondrial,
anti-[**Doctor First Name **]). It was thought that most likely cause was
statin-induced hepatoxicty resulting in painless cholestatic
jaundice. On [**2104-6-11**] however, liver function tests starting
increasing with worsening of synthetic liver function. Liver
consult team was consulted and were considering liver biopsy if
liver function continued to worsen. Additional tests such as
ceruloplasmin, anti-SLA, HSV serology and alpha-1-antitrypsin
were sent. Her synthetic function continued to worsen with INR
trending from 1.7 to 5.8 over the course of 2 days. It was felt
that she may be developing fulminant hepatic failure at that
time and she was transferred to MICU for closer monitoring as
well as evaluated by liver transplant surgery for possible
transplant. Mental status was normal. Her next INR was measured
at 2.2 however with only 5mg subcutaneous vitamin K administered
between the 2 measurements and she was transferred back to the
floor. On the floor, INR continued to trend down and was 1.0 at
time of discharge. Etiology of liver failure not entirely clear,
but felt to be most likely related to statins. She will follow
up in liver clinic as an outpatient 1 week after discharge. She
will need liver function tests monitored every other day for 1
week then weekly afterwards.
.
#. Rhabdomyolysis: Patient presented with proximal muscle
weakness and was found to have severe rhabdomyolysis, likely
statin-induced. On admission patient had an inability to abduct
shoulder and flex quadriceps secondary to pain. CK levels
improved from 22,215 on admission to 15,900 on [**2104-6-12**] with IV
fluids, however then worsened to 23,500 despite continued
fluids. At time this time it was decided to proceed with muscle
biopsy as she was worsening after an initial improvement. Muscle
biopsy results were still pending at time of discharge, however
CK's started trending down again and were 6784 at time of
discharge. Her IV fluids were discontinued but oral fluids
should be encouraged for 1-2 liters daily. Patient was able to
ambulate with minor assistance. Physical therapy was consulted
and the decision was made to send the patient to a
rehabilitation facility for the improvement of her proximal
muscle weakness.
.
#. Acute Renal Failure: Most likely mechanism is statin-induced
rhabdomyolysis causing myoglobinurea leading to tubular
obstruction and acute renal failure. Patient was treated with
aggressive IV fluid resuscitation for 9 days. Patient's creatine
improved from 3.1 on admission to 1.0 at time of discharge.
Patient should have routine BUN/creat levels checked weekly
after discharge.
.
# Hypokalemia: Patient has several episodes of hypokalemia to
2.9 likely from IV fluid resuscitation. She was repleted without
difficulty. Potassium 2.9 on morning of discharge and she was
repleted with 40mg IV and 40mg PO potassium. Potassium should be
checked daily until normal for 2 consecutive days.
.
#. Volume overload: Development of trace edema in feet, arms &
legs on day 4 of hospitalization that progressively worsened as
IV fluid resuscitation was continued. However, no signs of
crackles, wheezes were noted and she had no oxygen requirement.
She received IV lasix with IV fluids for forced diuresis. She
will continue to mobilize fluids as her mobility improves and IV
fluids are discontinued. She may receive additional diuresis
with lasix if her creatinine remains stable.
#. CAD: Patient with history of On admission patient denies
chest pain. Lisinopril and statin were held as above. She was
continued on her Metoprolol and ASA. Patient remained
normotensive throughout hospitalization with no evidence of
active ischemia. Lisinopril should be restarted when CK returns
to a completely normal value and creatinine is at baseline.
#. Hyperlipidemia: On admission patient was on atorvastatin 80mg
daily for lipid control. This was discontinued as described
above and statins are now described as an allergy and
contra-indicated for this patient. She has history of CAD with
recent CABG therefore needs better control of her cholesterol
with a different [**Doctor Last Name 360**]. She will be referred to lipid clinic
for consideration of another treatment regimen to reduce her
hyperlipidemia once liver function recovers.
.
# Dispo: Patient was discharged to rehab for continued physical
therapy
Medications on Admission:
Atorvastatin 80 mg PO daily
Ibuprofen 400mg PO TID PRN
Lisinopril 5 mg PO daily
Metoprolol Tartrate 50 mg TID
Aspirin 325 mg PO daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehab & [**Hospital **] Care Center [**Location (un) **]
Discharge Diagnosis:
Primary:
-Rhabdomyolysis induced by statins
-Statin-induced cholestastic jaundice
-Acute liver failure
-Acute renal failure, [**2-11**] Pigmented Nephropathy
Secondary:
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
It was a pleasure taking care of you during your recent stay at
[**Hospital1 18**]. You were admitted with muscle pain and weakness and found
to have muscle breakdown related to statin use. We stopped the
statin, gave you fluids and provided physical therapy.
You also showed signs of liver damage likely from the statin as
well. You will need to follow up in the liver clinic as
directed.
The following changes were made to your medications:
1) Stop Atorvastatin
2) HOLD Lisinopril - this will be restarted at rehab
Please call Dr. [**Last Name (STitle) **] if you feel worsening muscle
soreness, weakness, chest pain, shortness of breath,
lightheadedness, fevers, chills or any other symptoms that are
concerning to you
Followup Instructions:
Please follow-up with PCP [**Name Initial (PRE) 176**] 2 weeks after discharge.
Please follow up in liver clinic as directed below.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2104-6-25**] 11:30
Completed by:[**2104-6-17**]
ICD9 Codes: 5849, 2768, 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4475
} | Medical Text: Admission Date: [**2123-9-25**] Discharge Date: [**2123-10-1**]
Date of Birth: [**2052-7-10**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
headache, leg pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
History was limited secondary to encephalopathy and obtained
from wife.
71M with history of DM, HTN, dCHF among other issues recently
admitted for binocular vision loss and bilateral upper extremity
weakness presents with severe headache and fever.
Headache began last night suddenly at rest, was [**11-3**] bifrontal,
and accompanied by nausea and left lower extremity rash painful
to touch. He denied chest pain or shortness of breath. He did
endorse an episode of urinary incontinence, which his wife
attributes to weakness and inability to make it to the bathroom
in time. His wife also reports "memory lapses" overnight and
this morning such as forgetting names he should know.
In the ED, initial VS were: Triage T98.8 HR93 BP120/56 RR16
SpO2:96% RA
Past Medical History:
-CAD with LBBB
-AV block s/p pacemaker in [**4-5**]
Model: [**Company 1543**] Adapta dual-chamber pacemaker
Rhythm: 95% atrial and ventricular sensed, 5% atrial paced, less
than 1% ventricular paced. There was no atrial fibrillation or
ventricular high-rate activity.
Mode: MVP mode, AAIR/DDDR, lower rate 60 bpm, maximum sensor
rate 110 bpm. The mode switch feature is ON for atrial rates
greater than 175 bpm.
- History of Diastolic heart failure
-HTN
-DM type II
-diabetic neuropathy
-OSA on CPAP
-HLD
-gout with podagra
-chronic LBP
-colonic polyp [**2120**]
-ED, on testosterone
-s/p R knee replacement
-s/p cataract surgery [**2118**]
-RFA R-GSV [**2119**]
-left knee arthroscopy, partial medial meniscectomy and
chondroplasty [**2121-4-8**]
Social History:
Resides with wife [**Name (NI) **].
-Employment: former construction worker
-Tobacco history: 14-pack-year smoking history and quit 40 years
ago
-ETOH: occasionally 1 drink (every ~6mo), was a "partier" in his
20s but denies alcohol dependence
-Illicit drugs: denies
Family History:
Significant for colon cancer in his mother who is currently [**Age over 90 **]
years old, father deceased who had prostate cancer. 2 brothers
with CAD 50s-60s, one died with CAD, one with recent pacemaker,
though he is one of 14 children.
Physical Exam:
Admission Physical Exam:
General: AAOx2, appeared in mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, obese, hard to assess JVP
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: foley
Ext: warm, well perfused,
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
neck ROM without rigidity
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6 151/80 79 18 96RA
8hr I/O: 0/1400
24hr I/O: unclear/5325
[**Name2 (NI) **]: AAOx3, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, obese, difficult to assess JVP, ?10cm
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, pacemaker in place at left upper pectoris
Lungs: CTAB
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: penis without rashes/lesions. No groin lesions/rash noted.
Ext: LLE with erythema, edema confined to marked area. Compared
to yesterday, the area is warmer and more red. Edema is status
quo compared to yesterday.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
neck ROM without rigidity
Pertinent Results:
ADMISSION LABS:
[**2123-9-25**] 11:20AM BLOOD WBC-12.8*# RBC-5.08 Hgb-17.2 Hct-49.7
MCV-98 MCH-33.9* MCHC-34.6 RDW-14.0 Plt Ct-101*
[**2123-9-25**] 11:20AM BLOOD Glucose-181* UreaN-15 Creat-1.1 Na-136
K-4.1 Cl-96 HCO3-27 AnGap-17
[**2123-9-25**] 08:43PM BLOOD Type-ART Temp-36.7 O2 Flow-15 pO2-57*
pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
DISCHARGE LABS:
[**2123-10-1**] 07:30AM BLOOD WBC-5.2 RBC-4.56* Hgb-15.6 Hct-44.8
MCV-98 MCH-34.2* MCHC-34.8 RDW-14.1 Plt Ct-167
[**2123-9-27**] 08:15AM Neuts-77.8* Lymphs-11.4* Monos-10.2 Eos-0.4
Baso-0.1
[**2123-10-1**] 07:30AM BLOOD Glucose-96 UreaN-10 Creat-1.0 Na-140
K-4.0 Cl-100 HCO3-32 AnGap-12
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
URINE:
[**2123-9-25**] 02:01PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2123-9-25**] 02:01PM URINE RBC-13* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
MICRO:
Anaerobic Bottle Gram Stain ([**2123-9-28**]): GRAM POSITIVE COCCI IN
CLUSTERS.
CSF;SPINAL FLUID: gram stain and culture negative, no growth.
URINE CULTURE (Final [**2123-9-29**]): YEAST. <10,000 organisms/ml.
Blood culture x3: pending
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
ECG [**2123-9-25**] 8:21:38 PM
Sinus tachycardia. Left bundle-branch block. Compared to the
previous tracing of [**2123-9-25**] there is slight slowing of the sinus
rate. Left bundle-branch block pattern persists.
Rate PR QRS QT/QTc P QRS T
106 186 148 356/436 60 -20 130
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT HEAD [**9-25**]: No evidence of an acute intracranial process. MRI
would be more sensitive for intracranial infection, if
clinically warranted.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CXR [**9-25**]: No acute cardiopulmonary process.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT [**9-25**]: Left lower leg cellulitis. No subcutaneous air to
suggest necrotizing fasciitis. No rim-enhancing fluid
collection. Possible left peroneal deep venous thrombosis. Left
lower extremity ultrasound is recommended for further
evaluation.
_
_
_
_
_
_
_
_
________________________________________________________________
LENIs
[**9-26**]: The paired peroneal veins within the left calf were not
well assessed due to overlying edema. Deep venous thrombosis
therefore in these veins cannot be excluded. No evidence of
deep venous thrombosis demonstrated elsewhere within the left
lower extremity.
[**9-29**]: No DVT in the left lower extremity.
Brief Hospital Course:
71M history of DM, HTN, dCHF presented with severe HA, fever and
encephalopathy who was initially admitted to the MICU for
encephalopathy in setting of sepsis from cellulitis. Also
question of left popliteal DVT.
# Fever/sepsis: Initial concern for possible
meningitis/encephalitis given presence of sepsis along with
altered mental status and headache. He was started on broad
coverage with Vanc, Ceftriaxone, Unasyn, and Acyclovir as LP was
difficult in the ED. Patient's lactate, temperature,
hemodynamics and mental status were all noted to improve
overnight. LP by anesthesia on hospital day two did not show
evidence of infection and acyclovir was discontinued. Patient
was noted to have left lower extremity cellulitis which was the
most likely source of his sepsis.
#Cellulitis: As described above, his fever/sepsis was likely
attributed to his lower left leg cellulitis. There was no
clinical evidence of necrotizing fascitis. After transfer to the
medical floor, he was continued only on Vancomycin and Unasyn
until [**2123-9-30**], when he was switched to po Bactrim/Keflex.
However, his cellulitis did not continue to improve on this
regimen. Thus, the morning of discharge a PICC line was placed
and he will continue on IV Vancomycin at a [**Hospital1 1501**] for a total
course of 14 more days, ending on [**10-15**]. His leg should continue
to be elevated to promote venous return.
# Bacteremia: He was found to have G+ cocci in clusters (Staph)
on one blood culture. This bacteremia [**2-25**] contaminant vs
cellulitis. His continued coverage with Vancomycin is
sufficient to treat this.
# Shortness of breath/hypoxemia
He presented with shortness of breath/hypoxia requiring oxygen
on admission. Overall picture may be consistent with
hypoventilation as there does not appear to be significant V/Q
mismatch, shunt, or heart failure exacerbation. MI ruled out
with serial ECG and cardiac biomarkers. There was a concern of
left peroneal dvt on CT of the leg, however after further
imaging with LENIs and review with the radiologists, it does not
appear that this was actually a DVT. He was treated for a 4 day
course of lovenox until it was established that this was not a
DVT. No further anticoagulation was required.
# Acute encephalopathy
Resolved with treatment of sepsis, was most likely toxic
metabolic in setting of acute sepsis.
# Headache:
Patient underwent non-con CT which did not show evidence of
acute bleed. Had LP which did not show evidence of infection or
bleed. Most likely related to volume depletion in setting of
sepsis. His headache resolved with pain medication and fluid
resuscitation.
# Tinea cruris: He developed jock itch with minimal erythema of
his intertriginous area. Responded will to terbinafine cream.
Should continue as needed.
Chronic Issues:
# DM2 : well controlled on his home regimen of lantus and apidra
SSI, oral hypoglycemics.
# OSA - continued CPAP
# CAD - continued aspirin 325mg daily
# diastolic CHF: stable, dry weight of 139lbs. Continued home
dose of lasix
Transitional Issues:
1. Cellulitis treatment with Vancomycin for an additional 14
day course, ending [**2123-10-15**]. Picc line will provide access for
IV abx and he will remain at a [**Hospital1 1501**] for antibiotic
administration. His left leg should continue to be elevated to
promote venous return.
2. Please adhere to his insulin regimen as he is part of a
[**Last Name (un) **] diabetes study. Please record all blood sugars on his
personal home tracking sheet.
3. Follow-up pending labs: blood cultures x3.
4. Code status: full code
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/Caregiver[**Name (NI) 581**].
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Glargine Unknown Dose
3. GlipiZIDE 5 mg PO Frequency is Unknown
4. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
5. Furosemide 40 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES [**Hospital1 **]
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE 5 mg PO DAILY
5. Glargine 74 Units Breakfast
Insulin SC Sliding Scale using glulisine Insulin
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Apidra *NF* (insulin glulisine) 4 UNIT Subcutaneous ASDIR
Reason for Ordering: Maintaining home sliding scale.
Administer as a sliding scale insulin: if FS> 250 in the
morning, at noon, or before dinner give 4 Units of Apidra.
Check FS at bedtime, but do not give Apidra regardless of FSG
level.
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Senna 1 TAB PO BID:PRN Constipation
11. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **] rash
apply to groin area
12. Vancomycin 1000 mg IV Q8H
13. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
14. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center
Discharge Diagnosis:
Cellulitis
CHF
Tinea cruris
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 52**],
It was a pleasure taking care of you while you were admitted to
[**Hospital1 18**]. You were admitted with a severe headache and leg pain.
You were found to have cellulitis (a skin infection) of your
left lower leg which was treated with IV antibiotics. We tried
to switch your regimen to oral antibiotics, but this was
actually less effective in your case. You restarted IV
Vancomycin antibiotics for further treatment of your cellulitis.
You had a PICC line place which is a special IV access to allow
continuation of IV antibiotics at home.
You were also found to have some fluid overload which caused
some difficulty breathing. Initially you required supplemental
oxygen, but after the fluid was removed with medication, you
returned to your baseline.
Additionally, there was concern for a possible clot in the left
lower leg. You were treated with a blood thinner while you were
in the hospital. However after further imaging work-up, there
was no further DVT and continuation of blood thinner medications
was not necessary.
weight goes up more than 3 lbs. You should also call your doctor
if you notice any difficulty breathing or chest pain.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2123-10-22**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2124-3-23**] at 8:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2124-3-23**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2123-10-3**]
ICD9 Codes: 5849, 4280, 3572, 4019, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4476
} | Medical Text: Admission Date: [**2112-2-11**] Discharge Date: [**2112-3-2**]
Date of Birth: [**2036-3-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
rapidly progressive weakness
Major Surgical or Invasive Procedure:
Trach placement
History of Present Illness:
Mr. [**Known lastname 58941**] is a 75 year old man with hx of BPH, HTN,
depression and high cholesterol who presented yesterday evening
to [**Hospital6 2561**] with "inability to speak". The history
is very limited because the patient was unable to talk and no
one
accompanied him to the hospital to relay the history. From
information gathered at [**Hospital3 **], the patient was feeling OK
today until sometime this evening after eating dinner. Time
course and exact contents of the meal are not known, but he
apparently communicated (in writing) that the food was homemade
and leftovers. He arrived at [**Hospital3 **] at 7:30-8:00PM.
Vitals on arrival were: BP 154/86 HR77 RR21 98%on RA. While
there, could only say one or two words at a time-other details
of
initial exam not documented in available paperwork. He had a
head CT which was negative. Around 11:50PM, he vomited and was
given Zofran. At 1:00AM, he wrote "please I need help, I think
I'm dying". He was reassessed and seen by neurology at some
point. He repeatedly wrote "I'm dying" on paper. He was noted
to
have "expressive aphasia" and bilateral ptosis. There was
apparently concern for "cortical stroke" vs. toxin ingestion
such
as botulism. He was then transfered here for further evaluation
and MRI.
Past Medical History:
1. HTN
2. Depression
3. BPH
4. High cholesterol
Was hospitalized at [**Hospital3 **] in [**9-8**] for hyponatremia (?SIADH
from SSRIs) and failure to thrive. At that time he was noted to
have hx of weight loss in the past year of 20-25lbs
Social History:
-lives in [**Hospital1 8**] by himself
-Muslim
-no tobacco or etoh use as per son
Family History:
No known family history of neurologic disease as per son.
Physical Exam:
Gen: Thin, gaunt appearing male, in significant respiratory
distress +accessory muscle use
Neck: supple, no thyromegaly, no bruit
CV: Tachy, regular 2/6SEM
Lung: Clear to auscultation bilaterally
aBd: decreased BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, Oriented to person, place, and
time. He was unable to speak,though occasionally grunted.
Occasionally mouthed some words. Tried to communicate with
gestures, very frustrated by inability to communicate.
Comprehension appeared intact-could follow commands, cross
midline. Unable to repeat or name. No evidence of apraxia or
neglect. Respiratory distress prohibited further mental status
testing.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
+blink to threat from both directions. Eyes were midline and
conjugate on neutral gaze. +vertical gaze palsy (unable to look
up or down at all), bilateral abducens palsy. Bilateral ptosis.
Facial diplegia. Hearing grossly intact. Palate elevation
symmetrical. Gag absent. Unable to move tongue, no
fasciculations
observed.
Motor:
Normal bulk bilaterally. Tone slightly increased in lower
extremities. Occasional fasciculations observed in left quad.
No
pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Grossly intact to LT and pain
Reflexes:
B T Br Pa Ach
Right 3 2 2 4 3
Left 3 2 2 4 3
**brisk throughout with 3-4 beats of clonus at the knees
bilaterally
Crossed adductors
Toes were downgoing bilaterally
Gait/Coordination: Unable to assess
Pertinent Results:
138 101 18 / 116 AGap=10
3.9 31 0.8 \
CK: 68
Ca: 9.4 Mg: 1.8 P: 3.6
2.9 \ 13.9 / 199
/ 44.1 \
N:85.8 Band:0 L:9.7 M:3.2 E:1.1 Bas:0.1
PT: 12.8 PTT: 23.0 INR: 1.0
ABG: 7.26/67/69 (prior to intubation)
Chest CT [**2112-2-11**]:
FINDINGS: The endotracheal and gastric tubes are in satisfactory
position. There are no pathologically enlarged axillary, hilar,
or mediastinal lymph nodes. There is a 5-mm rounded density,
which is ill-defined, in the right upper lobe. There are
multiple other smaller ill-defined densities adjacent to this.
There are opacities in both lung apices, which could represent
pleural thickening or scarring. There is patchy air space
disease within the right lower lobe, with endobronchial spread.
There is also airspace disease of the right middle and left
lower lobes. There is calcification of the aortic arch and
descending aorta. The heart, pericardium and great vessels
otherwise are unrmarkable.
The stomach is full of ingested material.
Limited views of the upper abdomen show an unremarkable, liver,
gallbladder, spleen, and upper pole of the kidneys.
BONE WINDOWS: No suspicious osteolytic or sclerotic lesions.
IMPRESSION:
Airspace disease within the left lower lobe, right lower lobe,
and right middle lobes, consistent with infection. Aspiration
cannot be excluded.
EMG [**2112-2-11**]
Complex, abnormal study. The electrophysiologic findings are
consistent with a neuromuscular transmission disorder, with
evidence for pre- synaptic dysfunction and widespread fiber
blocking, as seen in botulism.
The differential diagnosis includes other pre-synaptic
neuromuscular
transmission disorders (e.g., [**Location (un) **] [**Location (un) **] myasthenic
syndrome); however, the rapidly progressive clinical picture and
pronounced ophthalmoplegia are atypical for this.
Brief Hospital Course:
The patient was admitted for management of his weakness. He was
intubated in the ER for respiratory distress and transferred to
the ICU. Subsequent blood testing revealed botulism toxin in
his blood. Approximately 24 hours after admission the patient
received the anti-toxin from the CDC flown in from [**Location (un) 9012**],
[**State 3908**]. Over the course of this admission, the patient
developed a pneumonia that was treated with a 7 day course of
unasyn (although it is likely this pneumonia was more of a
chemical pneumonitis as he was given activated charcoal prior to
admission and may have aspirated).
He also suffered from gastroparesis requiring frequent enemas,
nutritional supplementation with TPN, and an aggressive bowel
regimen. He was given several doses of neostigmine with the
hopes of improving bowel motility but he did not pass any
significant materail. He can continue TPN indefinitely until
bowel has fully recovered per nutrition consult. PICC line
placed on [**2112-2-20**] with tip in the distal SVC.
His ocular weakness has improved in that he is able to move his
eyes from side to side a bit, although still unable to open eyes
(bilateral ptosis). He remains with good distal extremity
muscle strength in the arms and legs, but poor proximal muscle
strength, unable to lift any extremity off the bed. He remains
on the ventilator with a trach collar. He is now being
discharged to rehab, afebrile and in stable condition but
requiring continued aggressive PT.
Note: He is completely awake and alert and can answer questions
using his hands. He is unable to open his eyes due to weakness
of his eyelids. This patient would benefit from speech therapy
and development of creative ways of communication (like pointing
to pictures when he wants to express something he wants, etc.)
He should undergo periodic trials of CPAP and pressure support
vent settings to see if he has regained his ability to breath
without the use of the vent.
He should also have aggressive PT/OT and range of motion
exercises.
Medications on Admission:
None
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-7**]
Drops Ophthalmic PRN (as needed).
4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Pantoprazole 40 mg IV Q24H
7. Metoclopramide 10 mg IV Q6H
8. Lorazepam 0.5 mg IV Q6H:PRN
9. Hydralazine HCl 10 mg IV Q4-6H:PRN SBP>150
10. Metoprolol 20 mg IV Q6H
Hold for SBP<120, HR<65
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
12. Famotidine in Normal Saline 20 mg/50 mL Piggyback Sig: One
(1) injection Intravenous Q12H (every 12 hours).
TPN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Botulism toxin poisoning
2. Pneumonia
3. Constipation
4. Hypertension
Discharge Condition:
stable with improving strength
Discharge Instructions:
Please return to nearest ER if symptoms worsen. Please take all
medications as prescribed. Please continue physical therapy.
Followup Instructions:
Please follow-up with Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], call
[**Telephone/Fax (1) 1040**] to schedule a convenient time 4 months from now.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5070, 486, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4477
} | Medical Text: Unit No: [**Numeric Identifier 63187**]
Admission Date: [**2155-7-9**]
Discharge Date: [**2155-7-24**]
Date of Birth: [**2155-7-9**]
Sex: M
Service: Neonatology
HISTORY: This is a 35 and [**1-27**] week male infant born to a 33
year old gravida II, para 0, mother whose pregnancy was
complicated by irregular heart beat and a normal echo
maternal. Prenatal labs are as follows: Blood type A
negative, antibody negative, RPR nonreactive, rubella immune,
hep B surface antigen negative and GBS negative. The infant
was born via rapid but normal spontaneous vaginal delivery
with Apgar scores of 8 and 9. Grunting began after delivery
and was referred to the NICU for further evaluation.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.5, heart
rate 156, respiratory rate 42, saturations 95% with blow by
oxygen. Blood pressure 76/38 with a mean of 52. Dextrostix is
72%. Weight was 2.850 kilograms. Head and neck normocephalic
atraumatic. Anterior fontanelle was open and flat. Positive
red reflex bilaterally. Neck supple. Lungs: Moderate air
movement, grunting, nasal flaring and occasional retractions.
Heart rate regular rhythm, no murmur, 2+ pulses bilaterally.
Abdomen soft, with active bowel sounds, no masses, no
distention. GU: Normal male, testes down bilaterally. Spine:
No dimple. Hips stable. Clavicles intact. Neurologically,
good tone and normal suck, gag. Anus patent.
HOSPITAL COURSE: By system:
Respiratory: The patient was placed on CPAP of 6 which was
weaned on day of life 2 to nasal cannula and was weaned to
room air on day of life 8. Blood gases were normal 7.32, 44.
Did not require caffeine therapy, stable.
Cardiovascular: No hypotension, normal blood pressure
throughout the entire stay. No cardiac medications. Current
blood pressure 76/48, mean of 59. Heart rate is 120s to 160s.
There is no murmur.
Fluids, electrolytes and nutrition: At birth, was placed on
IV fluids and parenteral nutrition until day of life 5 when
tube feeds were begun with breast milk. On day of life 7, the
patient began to eat breast milk ad lib every 3 hours and
breast feeding with mom. [**Name (NI) 21206**] had a lactation consultant visit
which thus helped her immensely. She is using nipple guards.
Current weight today is 2.775 kilograms, almost his birth
weight. Medications currently include Tri-Vi-[**Male First Name (un) **].
Hyperbilirubinemia day of life 4 requiring phototherapy until
day of life 7. Maximum bilirubin was 13.2, direct 0.3.
GI: Stable as above. Currently tolerating breast milk p.o. ad
lib demand taking at least 120 cc/kilogram/day, all p.o. with
normal urine output and normal stool.
On admission, white blood cells 9.3, hematocrit 48.5,
platelets 228,000, 47% neutrophils and 1 band.
Infectious disease: Blood culture was sent day of life 0, was
negative and the ampicillin and gentamicin were given for
the first 48 hours of life and discontinued. No further
antibiotic therapy was required during his hospital stay.
Neurology: Stable. Audiology screen performed, and infant passed
in both ears. Ophthalmology exam was not required due to advanced
gestational age.
Psychosocial: [**Hospital1 18**] social work can be reached at [**Telephone/Fax (1) 44202**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home. Primary care pediatrician is
[**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] in [**Location (un) 7658**], telephone number [**Telephone/Fax (1) 63188**].
Dr. [**Last Name (STitle) **] was present at our most recent family meeting and
she is up to date on the patient's course in the hospital.
Circumcision was declined by 2 obstetricians from Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 63189**] practice due to limited amount of skin on the penis
at this time. It was felt that the circumcision should be
postponed until further growth can be achieved.
DISCHARGE INSTRUCTIONS:
1. Feedings at discharge are breast feeding ad lib demand.
2. Medications include Tri-Vi-[**Male First Name (un) **] 1 ml p.o. daily.
3. Car seat positioning study was performed successfully.
4. State newborn screen was sent [**7-23**], repeated.
5. Immunizations will be received at the pediatrician's
office. None received here.
6. Immunizations recommended: Influenza immunization is
recommended annually in the fall for all infants once
they reach 6 months of age. Before this age, immunization
against influenza is recommended for household contacts
and out of home caregivers.
7. The patient has a follow-up appointment with Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES: Prematurity.
Respiratory distress syndrome, resolved.
Sepsis ruled out.
Status post hyperbilirubinemia requiring phototherapy.
Apnea and bradycardic spells not requiring caffeine.
In utero, the patient had a history of pyelectasis. A renal
ultrasound was done [**7-22**], and was normal. No
pyelectasis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (NamePattern1) 61253**]
MEDQUIST36
D: [**2155-7-23**] 18:39:22
T: [**2155-7-23**] 20:43:43
Job#: [**Job Number 63190**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4478
} | Medical Text: Admission Date: [**2193-5-23**] Discharge Date: [**2193-6-7**]
Date of Birth: [**2134-9-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
Hypertensie Urgency
Major Surgical or Invasive Procedure:
Intubation due to acute respiratory distress
.
Hemodialysis
History of Present Illness:
58 y/o female with h/o ESRD on HD, s/p renal tx in [**2173**] with
acute on chronic rejection in [**2193-1-20**], initially presenting
with a 4-5 days episode of severe frontal headaches, N/V/D and
decreased appetite. Pt reports symptoms started on [**5-18**] after
she had received dialysis that day. She missed her HD 2 days
prior to admission due to severe HA and malaise. Pt denies
having had changes in vision, numbness or weaknesses, syncopes,
SOB, CP, anuria or edema during that time.
During her next HD session on [**5-23**] it was noted that pt had SBP
>200-250 patient was also c/o headache and sent to ED for HTN
management. Pt was admitted to the ED for severe hypertensive
crisis, given captopril, labetolol 20mg, 40mgx2, 80mg then
started on nitro and labetolol gtt. She also received dilaudid
for her HA and she was transferred to the MICU for hypertensive
urgency and fevers (102).
.
MICU
She had two seizures on [**5-24**] in the early morning hours, most
likely due to hypertensive leucoencephalopathy. The first
tonic-clonic convulsion (at 4AM, lasting for about 3min) was
witnessed, a respiratory code was called but the intubation
failed (esophagus). At 6AM the pt awoke, was disoriented,
agitated and started screaming. Shortly after she suffered from
a second seizure which stopped after Lorazepam 2mg iv, pt was
then successfully intubated and entered brief post-ictal coma
(with intact brain stem reflexes).
Pt was transferred to the floor 48 hours later for
optimalization of her BP.
Past Medical History:
#S/p renal transplant in [**2173**], acute on chronic rejection in
[**1-25**], now ESRD on HD.
.
#IgA nephropathy in [**2169**], 7-8months HD prior to transplant
.
#HTN
.
#Depression
.
#s/p rheumatic fever in childhood
Social History:
Lives alone with cats. No family in the area. Denies
tob/EtOH/IVDU/substances. Works part-time as asst. coffee shop
manager. Unable to obtain health insurance for past year, which
has limited her access to f/u medical care for her transplant.
Family History:
Father died age 80.
Mother with lung Ca, died @64.
Many aunts/uncles with Ca.
Sister with breast Ca, survived.
No family hx renal problems.
Physical Exam:
T 99.6 BP 174/75 (146/66-190/96) HF 91 bpm (83-105 RR 18
(18-24)
O2-Sat 100%(97%)on 2l
I/Os: 1012/275, after midnight 1132/0
General Alert, orientated, cooperative; pleasant;
Skin Warm, good color, normal turgor; no signs of ulcers,
petechiae,
erythema or jaundice; Pt has bruises on her back (left
lower chest)
and arms; Mild bilat. LE edemas;
HEENT No visual impairment, no conjunctival injections,
anicteric sclerae;
Moist gums and tongue;
Lymph No signs of lymphadenopathy;
Neck Good carotid pulses, no bruits;
Respir No use of accessory muscles, no retractions,
symmetrical thorax
expansion, both lungs are equally ventilated, no
wheezes, crackles
over both lower lobes l>r, decreased BS over LLL;
Cardio Rhythmic, HR 91bpm, S1+ S2, systolic
crescendo-decrescendo [**2-25**]
murmur, no gallops or rubs;
Abdomen No skin liver signs, normal bowel sounds over all four
quadrants, no
pain on light or deep palpation, no guarding, no
masses; no
hepatospleno-megaly, no flank pain;
Pulses Good palpable carotic, radialis, ulnaris, dorsalis pedis
and tibialis
pos. pulses;
MuscSkel No swelling of joints, no redness, no warmth; normal
range of motion;
Neuro Coherent, alert and orientated; normal CN II to XII,
normal strength
[**5-24**],normal sensory on both arms and legs;
Pertinent Results:
[**2193-5-23**] 07:00PM GLUCOSE-86 UREA N-18 CREAT-5.4*# SODIUM-142
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-30 ANION GAP-17
[**2193-5-23**] 07:00PM ALT(SGPT)-11 AST(SGOT)-14 CK(CPK)-67 ALK
PHOS-58 AMYLASE-61 TOT BILI-1.0
[**2193-5-23**] 07:00PM LIPASE-27
[**2193-5-23**] 07:00PM cTropnT-0.04*
[**2193-5-23**] 07:00PM CK-MB-NotDone
[**2193-5-23**] 07:00PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.3#
MAGNESIUM-1.6
[**2193-5-23**] 07:00PM WBC-3.4* RBC-3.17* HGB-9.9* HCT-29.8* MCV-94
MCH-31.4 MCHC-33.3 RDW-19.1*
[**2193-5-23**] 07:00PM NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4
BASOS-0.3
[**2193-5-23**] 07:00PM NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4
BASOS-0.3
[**2193-5-23**] 07:00PM ANISOCYT-2+ MACROCYT-1+ MICROCYT-1+
[**2193-5-23**] 07:00PM PLT SMR-VERY LOW PLT COUNT-44*#
[**2193-5-23**] 07:00PM PT-12.4 PTT-23.4 INR(PT)-1.1
.
Upon d/c:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2193-6-7**] 04:50AM 5.6 3.76* 11.4* 33.9* 90 30.3 33.5 18.4*
148*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2193-5-29**] 05:17AM 55.4 33.1 6.5 4.1* 1.0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Bite Fragmen
[**2193-5-29**] 05:17AM 1+ 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2193-6-7**] 04:50AM 148*
MISCELLANEOUS HEMATOLOGY ESR
[**2193-6-4**] 07:00PM 7
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2193-6-7**] 04:50AM 80 22* 4.0*# 140 3.5 101 27 16
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2193-6-6**] 05:00AM 281*
OTHER ENZYMES & BILIRUBINS Lipase
[**2193-5-29**] 05:17AM 33
CPK ISOENZYMES CK-MB cTropnT
[**2193-5-23**] 07:00PM 0.04*
[**2193-5-23**] 07:00PM NotDone
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2193-6-7**] 04:50AM 8.6 4.3 1.7
HEMATOLOGIC Folate Hapto
[**2193-6-6**] 05:00AM <20*
OTHER CHEMISTRY Ammonia
[**2193-5-29**] 05:17AM 19
PITUITARY TSH
[**2193-6-1**] 06:20AM 2.0
OTHER ENDOCRINE Cortsol
[**2193-6-2**] 06:00AM 18.7
ANTIBIOTICS Vanco
[**2193-5-29**] 05:17AM 14.3*
NEUROPSYCHIATRIC Phenyto Valproa Phenyfr %Phenyf
[**2193-6-4**] 04:50AM 68
LAB USE ONLY GreenHd Prblm RedHold
[**2193-6-5**] 07:15AM AMARIE & J
.
ADAMTS 13: negative
Metanephrines Serum - wnl
HIT - negative
.
CT Head [**5-24**]:
IMPRESSION: Unchanged appearance of CT compared with the prior
examination obtained earlier on the same day. No hemorrhage is
seen. Hypodensities are again noted in the white matter
bilaterally. If hypertensive encephalopathy is clinically
suspected, MRI would be helpful for further assessment.
.
EEG [**5-25**]:
IMPRESSION: This is an abnormal portable EEG due to the presence
of
intermittent right central parietal and left temporal and
central sharp
transients. This finding appears to be independent and more
frequent
over the right side. Additionally, there are prolonged bursts of
generalized slowing, bifrontally predominant and slow and
disorganized
background rhythm. This abnormality suggests cortical
dysfunction over
the right central parietal region and possible left central and
temporal
region. The bursts of the generalized slowing and the background
slowing suggests a deep, midline subcortical dysfunction and are
consistent with an encephalopathy. There was no seizure activity
recorded.
.
Echo [**5-28**]:
Conclusions:
There is moderate symmetric left ventricular hypertrophy. 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 are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion.
.
MRI abdomen:
FINDINGS: Both native kidneys are markedly atrophic. Single
renal arteries are identified bilaterally, without evidence for
stenosis.
The transplant renal artery rises from the right external iliac
artery. There is no evidence for stenosis within the renal
transplant artery. This artery trifurcates approximately 1.4 cm
from its origin. The aorta is normal in caliber without evidence
for atherosclerosis. The common iliac, external iliac and
visualized portions of the common femoral arteries are widely
patent.
The transplanted kidney is identified in the right hemipelvis,
measuring 10.7 cm in length. There is severe cortical thinning.
The urothelium of the renal pelvis is abnormally thickened and
edematous and demonstrates enhancement on post-gadolinium
imaging. This finding is nonspecific, however, can be seen in
both rejection and infection. There is no significant
hydronephrosis of the transplanted kidney and no focal renal
lesions are identified.
The partially visualized liver is unremarkable. There is no
intra- or extrahepatic biliary dilatation. The pancreas and
adrenal glands are unremarkable. The spleen is abnormally low in
signal on T1-weighted imaging, consistent with iron deposition.
The visualized bowel is normal and there is no significant
lymphadenopathy.
IMPRESSION:
1. No evidence for renal artery stenosis in either the native
kidneys or transplant kidney.
2. Severe cortical thinning of the transplant kidney. Abnormally
thickened and edematous renal transplant urothelium. This is a
nonspecific finding that can be seen in rejection and infection.
Findings were discussed with Dr. [**Last Name (STitle) 6812**] at the time of the
examination.
.
MRI of the head:
IMPRESSION:
1. No interval change in multiple nonspecific foci of increased
FLAIR signal intensity throughout both cerebral hemispheres,
non-specific.
2. Apparent FLAIR-hyperintensity in the sulcal subarachnoid
spaces. This finding may represent a technical artifact, or less
likely blood products, cells or protein within the subarachnoid
space.
3. Normal MRA of the circle of [**Location (un) 431**].
.
Carotid US:
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaques identified.
On the right, peak systolic velocities are 106, 60, 87 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.6.
This is consistent with less than 40% stenosis.
On the left, peak systolic velocities are 75, 72, 78 in the ICA,
CCA, and ECA respectively. The ICA to CCA ratio is 1. This is
consistent with less than 40% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Brief Hospital Course:
58 y.o. F admitted for malignant hypertension after missing HD
session and nonadherent with her medications. Patient with
subsequent seizures due to severe hypertension and slowly
resolving confusion due to reversible hypertensive
leukoencephalopathy. Patient was also found to be in
microangiopathic thrombotic anemia with platelet consumption.
Her symptoms, confusion and cbc returned to her normal baseline
upon control of her blood pressure.
.
# Confusion
The pt presented with waxing and [**Doctor Last Name 688**] episodes of confusion
when she was transferred from the MICU to the floor. She was
disoriented to location, time and suffered from post-ictal
amnesia. The possible DDx included post-ictal vs. IC bleeding
(CT scan was negative) vs. secondary to leukoencephalopathy vs.
sepsis vs. delirium vs. medication. Since the pt mental status
improved steadily parallel to BP control, it was thought to be
reversible changes secondary to hypertensive
leukoencephalopathy. The pt has been stable over the past days
and is discharged with a fully recovered mental status.
.
# Fevers
Pt spiked temperature when still on the MICU and started on 7
day course of Ceftriaxone. Since the pt had signs of LLL
atelectasis on CXR a possible PNA could not be fully excluded.
The pt also just had been intubated and had central lines in
place. The obtained sputum showed Strep. pneumoniae and she was
treated empirically for that with ceftriaxone. Drug fever was
also in the differential since the pt showed no other signs of
infections (chills, elevated WBC, SOB) but remained with
intermittent fevers. She was newly started on phenytoin. After
she was changed to Valproic acid, pt remained afebrile over the
[**4-24**] prior to discharge and without any signs of active
infection.
.
#. Seizures:
Pt presented at MICU with new onset seizures, 2 generalized
clonic episodes (each about 3min), which required intubation. Pt
was monitored throughout post-ictal state and transferred to the
floor after she was stable. She has been seizure-free since
then.
Initial seizures likely [**2-21**] HTN emergency - hypertensive
leukoencephalopathy. Patient did not have evidence of trauma,
systemic infection, no electrolyte abnormalities especially with
ESRD, no evidence of acute bleed with underlying
thrombocytopenia.
- Head CT negative x 2 on [**5-24**] negative for hemorrhage or mass,
MRI was not thought to be necessary at this point, neuro recs.
- EEG impression: Suggests cortical dysfunction over the right
central parietal region and possible left central and temporal
region. The bursts of the generalized slowing and the background
slowing suggests a deep, midline subcortical dysfunction and are
consistent with an encephalopathy. There was no seizure activity
recorded.
Pt was initially started on phenytoin for seizure prophylaxis to
which she responded well. However, pt developed a fever which
was thought to be drug induced (eosinophilia accompanied febrile
episode). Therefore phenytoin was d/c and pt was started on
valproic acid instead. Her valproic acid have been monitored
closely to titrate dosage, currently she is on Valproic acid
500mg po bid standing, last valproic level on [**6-3**] was 75.
Pt will f/u with neurology as an outpatient to adjust further
treatment.
.
#. Hypertension:
Pt was admitted for hypertensive urgency with end organ damage -
hypertensive leukoencephalopathy and microangiopathic hemolytic
anemia. Obtained secondary hypertension work-up was negative
(incl. MRI Abdomen, TSH, Cortisol - serum epinephrine and
metanephrine were within normal limits).
She has a history of not taking her medications, missing HD may
also have complicated situation along with worsening renal
failure/hypoperfusion/high RAAS. History from previous admission
of bp elevated >200s but responded to Lasix and labetalol. Pt in
ED initially was started on nitro gtt and nipride gtt in ED.
Drips were stopped after seizures and improved BP control. There
were no ECG changes or evidence of cardiac ischemia.
BP was hard to control at first but stabilized over the past 72h
under enforced treatment with Labetalol, Lisinopril, Clonidine,
Nifedipine and intermittent Hydralazine (which was d/c on [**6-2**],
due to orthostatic symptoms). Repeated adjustments in BP-regimen
were made to optimize current treatment and prevent hypotensive
episodes.
Pt is discharged on Lisinopril 40mg po to qhs, Clonidine TTS 3
patch qthurs, Labetalol 800mg po bid and Nifedipine 120mg po
qhs.
The set goal for her SBP is 120-170, since the pt probably has a
history of long-standing maltreated HTN and is used to high
pressures. She complains about light-headedness and dizziness
once pressures get too low. However, given her recent
hypertensive episode it is essential for her to be well
controlled. Also considering a component of non-compliance it is
important that the pt will f/u with PCP and for monitoring of
compliance.
.
#. ESRD
Pt is s/p renal transplant in [**2173**] and tx rejection in [**Month (only) 404**]
[**2193**], now back on HD, 3 times a week. Pt received HD throughout
her hospital course and will be followed by renal as an
outpatient, receiving HD at the [**Hospital1 18**].
She will be continued on her prednisone taper for immuno
suppression with her graft. There was no evidence of
compromising renal artery stenosis on the MRI.
HD per their schedule, next HD sessioned for [**6-8**].
.
#. CN III palsy
Pt had two episodes of right sides ptosis/lat.
deviation/diplopia and mydriasis (reactive to light),
accompanied by right hemicranial HA during HD on [**6-4**] -
resolving within 10 minutes.
Initial DDx included Arteritis temporalis (ESR 7) vs. TIA vs.
right posterior artery aneurysm. The obtained work-up included
MRI/MRA (questionable subarachnoidal bleeding), carotid duplex
(minimal bilat. stenosis <40%) and LP (no xanthocromia,clear and
colorless).
Since the clinical findings (ptosis, lat. deviation, mydriasis
or diplopia)totally resolved and the work/up was negative, the
intermittent CNIII palsy is thought to be secondary to transient
ischemia due to hypotension.
Pt will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**], neurologist as an
outpatient.
.
#. Severe Headache
Pt presented with severe fronto-facial HA, accompanied by N/V on
[**6-6**] (day after LP). She reported that the HA was similar to the
one on her initial presentation.
The HA was thought to be triggered by pt not following
instruction after LP, such as bed-rest and high pressure
overnight (up to 220s SBP. HA resolved throughout the day,
initially treated with Oxycodone-Acetaminophen and Fioricet for
HA, as well as Dolasetron for nausea. Neuro saw pt and did not
find signs for focal lesion or papilledema, which could be
indicative for post-LP complications.
Pt is asymptomatic on day of discharge, denying HA, N/V,
dizziness or blurry vision this am.
.
#. Anemia - Normocytic.
Pt initially presented with Hct of 29.8, normocytotic. The
anemia is thought to be secondary to ESRD (not treated with EPO
previously) vs. occult bleeding vs. hemolysis. Retic count in
[**Month (only) 404**] was 1.4%, indicating an impaired production. The
hemolysis studies obtained revealed an elevated LDH and a
decreased haptoglobin, which are found in hemolysis.
The anemia is thought to be secondary to ESRD and initial
microangiopathic hemolytic anemia induced by hypertensive
urgency.
Hct slightly decreased over the days prior to discharge, 32.3 on
[**6-2**] to 25.6 on [**6-6**]. Hemolysis labs obtained revealed elevated
LDH (not compared to previous days), Haptoglobin <20 (measured
twice), normal direct and total Bili. No signs of active
bleeding, pt is asymptomatic (denies SOB, not tachycardic, no
dizziness) nor signs of severe hemolysis (jaundice,
splenomegaly).
Anemia and decrease in Hct is thought to be due to ESRD, ACD and
hospital course (HD, frequent blood draws). However, labs
indicate an additional hemolytic component.
Pt was given 2 Units of Blood on [**6-6**] at HD, in addition to
usual Epoetin administration during HD sessions.
She responded adequately to transfusion, Hct rose from 25.6 to
28.1 to 33.9 in am of [**6-7**].
.
#. Thrombocytopenia
Pt initially presented with ptl of 44. The thrombocytopenia were
thought to be either microangiopathic hemolytic anemia secondary
to her hypertensive urgency vs. TTP. Indicative for an
underlying TTP are the following findings are thrombocytopenia,
hemolysis, schistocytes, elevated LDH, decreased haptoglobin,
elevated creatinine, mental status changes and fever.
However the obtained ADAMTS13 to test for TTP was negative.
Given that the pt Hct stabilized once her BP was controlled
better made a MHA secondary to hypertensive crisis most likely.
Interestingly, the pt had a similar thrombocytopenic episode in
[**2193-1-20**] when she was hospitalized for her renal tx
rejection.
The ptl count has been steadily increasing since [**5-24**], being 148
on day of discharge.
.
# Full code
Medications on Admission:
Meds at home:
Labetalol 600 mg daily
ASA
Lipitor
Prednisone 5mg
Folic Acid
.
Upon Transfer:
Labetalol HCl 300mg po tid
Lisinopril 10mg PO daily
Aspirin 81mg po daily
Prednisone 5mg po daily
traZODONE HCl 25mg po hs:prn
Phenytoin 100mg iv q8h
Oxymetazoline HCl 1 spry nu [**Hospital1 **]:prn
Amoxicillin 500mg po q24h
Acetaminophen 325/650mg po q4-6h:prn
Senna 1 tab po bid:prn
Magnesium Sulfate 2gm/100ml NS iv ONCE
ISS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
Disp:*240 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
8. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
Disp:*120 Capsule(s)* Refills:*2*
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO ONCE MR1 (Once and
may repeat 1 time) as needed for insomnia for 1 doses.
Disp:*15 Tablet(s)* Refills:*0*
11. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency with secondary leukencephalopathy and
microangiopathic hemolytic anemia
.
ESRD, s/p renal transplantation in [**2173**], tx rejection in [**1-25**]
now back on dialysis
Discharge Condition:
Stable
Discharge Instructions:
Please go to [**Hospital 101208**] Clinic tomorrow to have your blood pressure
checked by a nurse.
.
Please see your primary care physician or present to the ED for
any of the following symptoms: headaches, blurry vision, changes
in vision, nausea, vomiting, chest pain, shortness of breath,
swelling of your legs, weaknesses of limbs or any other symptoms
that worry you.
Followup Instructions:
Please have your blood pressure checked at the Women's Clinic at
Carny tomorrow;
.
Your next scheduled appointment for dialysis at the [**Hospital1 18**] is on
thursday, the [**6-6**].
.
Please see Dr. [**Last Name (STitle) **], [**Doctor Last Name **], Neurology on thursday, [**6-6**] at
1pm on neurology unit CC8 (SB) for seizure follow-up.
[**Telephone/Fax (1) 44**].
.
You have an appointment with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 101209**], [**Known firstname **] [**Last Name (NamePattern1) 5969**] scheduled for Monday, [**6-10**] at 2.30pm,
Women's Clinic at [**Hospital 101208**] hospital. [**Telephone/Fax (1) 101210**].
.
You also have a set appointment with your therapist [**First Name8 (NamePattern2) 101211**] [**Doctor Last Name **]
for Monday [**6-10**] at 6pm, Women's Clinic at [**Hospital 101208**] hospital.
[**Telephone/Fax (1) 101210**].
Completed by:[**2193-7-2**]
ICD9 Codes: 5856, 486, 5990, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4479
} | Medical Text: Admission Date: [**2164-5-23**] Discharge Date: [**2164-6-3**]
Service: Medicine, [**Hospital1 **] Firm
CHIEF COMPLAINT: Gastrointestinal bleed
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
male with a history of a diverticular bleed while on Coumadin
for a stroke who had initially presented in [**Month (only) **] of
to find the source of the bleed, but failed intervention.
The patient then underwent a partial colectomy and ileocolic
anastomosis at [**Hospital3 **] Medical Center on [**2163-10-8**].
His hospital course there was complicated by intubation and
tracheostomy for failure to wean, as well as PEG placement
for feeding. The patient, at that time, was discharged to
[**Hospital1 5042**] for a period of three months where he was weaned from the
tracheostomyt , and subsequently went to the [**Hospital **], where he was weaned from the PEG. He was
discharged home. The patient was doing
well, but recently seen at an outside hospital for aspiration
pneumonia and Methicillin resistant Staphylococcus aureus
sputum, requiring intubation, improved and discharged on
Bactrim back to the [**Hospital 19497**].
However, on [**4-23**], the patient was noted to have
abdominal pain, was found to have melena and clots from his
ileostomy. The patient was then admitted to the MICU at the
[**Hospital6 256**] and found to have a
hematocrit of 30.0. The patient underwent angiography by
interventional radiology which failed to detect bleed in his
mesenteric arteries. The patient was subsequently scoped
with an esophagogastroduodenoscopy on [**2164-5-24**] which
showed two large and one small duodenal ulcers. The patient was
placed on
Prilosec therapy for these duodenal ulcers. Of note,
Helicobacter pylori studies also came back positive and the
patient was to be started on triple antibiotic therapy. For
the gastrointestinal bleed, the patient was transfused 5
units of packed red blood cells.
During the patient's MICU course, he was also noted to have
elevated potassium and had a random cortisol to assess the
question of renal insufficiency, but the result was not
consistent with the diagnosis. The patient was also noted to
have increased white blood cell count to 31.6 and was found
to have gram positive cocci on his blood cultures on
admission from his triple lumen catheter, now identified as
Staphylococcus epidermitis.
The patient did well in the MICU with a stable hematocrit and
had denied lightheadedness, abdominal pain and bright red
blood per ostomy and on [**2164-5-25**], was transferred to
the medicine service for further work up.
PAST MEDICAL HISTORY:
1. Diverticular bleed while on Coumadin for cerebrovascular
accident, status post subtotal colectomy with side to side
ileocolic anastomosis at [**Hospital3 **] Medical Center on
[**2163-10-12**].
2. History of prostate cancer, status post XRT and
orchiectomy.
3. Renal cell carcinoma, status post left nephrectomy.
4. Cerebrovascular accident with recent aphasia in [**2163-4-2**] for which she was on Coumadin which was discontinued on
10/[**2163**].
5. History of Methicillin resistant Staphylococcus aureus
pneumonia.
6. Depression
7. Hypothyroidism
8. History of aspiration pneumonia
9. Status post trach and PEG placement, both of which are
now removed.
10. Left diaphragm paralysis.
11. Question history of heart block and [**Hospital1 5042**].
12. Bilateral inguinal hernias repaired in [**2125**].
ALLERGIES: No known drug allergies, BUT THE PATIENT IS
SENSITIVE TO ADHESIVE TAPE.
SOCIAL HISTORY: The patient is DNR/DNI and is a patient at
the [**Hospital 19497**]. The patient is married with
children
ADMISSION MEDICATIONS:
1. Synthroid 0.5 mg po q day
2. Megace 800 mg
3. Bactrim
4. Aspirin 81 mg po q day
5. Ritalin 5 mg po q day
6. Albuterol metered dose inhaler
7. Atrovent metered dose inhaler
8. Prilosec 20 mg po q day
TRANSFER MEDICATIONS FROM MICU ON [**5-25**]:
1. Synthroid 0.75 mg po q day
2. Vancomycin 1 mg po q 12 hours
3. Prilosec 40 mg po bid
4. Albuterol and Atrovent metered dose inhalers
LABORATORIES: The patient's admitting hematocrit on [**5-23**] was
30.0. After 5 units of blood, the patient's hematocrit
remained stable at 31 to 32. On transfer to the medical
floor, the patient's hematocrit was 31.6. Chemistries were
within normal limits. BUN and creatinine were 35 and 1.0
respectively. TSH was 4.0. Cortisol was 9.9. Helicobacter
pylori was positive.
IMAGING: A chest x-ray from [**5-25**] showed right retrocardiac
density and a left hemidiaphragm elevation which was known to
be old. A mesenteric angiogram on [**5-23**] showed no evidence of
bleed. A KUB from [**5-23**] showed no evidence of free air.
PHYSICAL EXAM ON TRANSFER:
VITAL SIGNS: Temperature 98.5??????, pulse 88, blood pressure
141/50, respiratory rate 20, O2 saturation 94% on room air.
GENERAL: The patient was a pleasant elderly gentleman in no
apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light, left surgical pupil. The patient's
oropharynx was clear. Mucous membranes moist.
NECK: Right IJ catheter.
LUNGS: Rancorous throughout the right lung at expiration.
HEART: Regular rate and rhythm, normal S1, normal S2.
ABDOMEN: Soft, nontender, nondistended with positive bowel
sounds. There was an ostomy on the patient's right lower
quadrant that showed dark stool, but not tarry.
EXTREMITIES: No edema. There was venostasis changes in his
lower extremities bilaterally.
NEUROLOGIC: The patient was alert and oriented to the [**Hospital1 **] in
[**Month (only) 547**]. The patient's speech was slightly dysarthric, known
to be old. The patient moved all four extremities. His deep
tendon reflexes were 2+ throughout. Cranial nerves II
through XII were intact.
HOSPITAL COURSE: In summary, an 85-year-old gentleman with
subtotal colectomy and ileocolic anastomosis presents with an
upper gastrointestinal bleed secondary to duodenal ulcers
which was found to be Helicobacter pylori positive. Upon his
transfer from the MICU, the patient's hematocrit remained
stable and while he had guaiac positive stools, he had no
bright red blood per ostomy. The patient was started on a
clear liquid diet and started on amoxicillin, Biaxin and
Prilosec for triple therapy of his Helicobacter pylori. The
patient also remained on high dose Prilosec for treatment of
his duodenal ulcers.
On [**2164-5-28**] the patient developed lower abdominal pain,
as well as bilious vomiting. A KUB showed elevated loops of
bowel consistent with small bowel obstruction. The patient
was evaluated by surgery, in which the patient was made NPO
and a nasogastric tube was placed. The patient also received
a tube in his ileostomy for decompression through his
ileostomy site to decompress his small bowel. The patient
underwent a CT of the abdomen on [**2164-5-28**] which showed
distended small bowel loops with distention all the way to
the level of the ileostomy site. There was some question of
whether there was focal narrowing at the ileostomy site
versus generalized ileus. In addition, the patient had a low
density lesion present in the right lobe of the liver which,
on further review, was known to be old.
The remainder of the [**Hospital 228**] hospital course and plan will
be detailed by system:
1. PARTIAL SMALL BOWEL OBSTRUCTION: At this point, the
patient continues to remain NPO on TPN with a nasogastric
tube. There was some discussion with surgery whether the
patient may require a surgical procedure to assess whether
adhesions are the source of the patient's obstruction. The
patient underwent a barium enema per surgery to assess the
patency of the ileosigmoid anastomosis and the ilium distal
to the stoma. This was performed on [**2164-5-31**] which showed
that the patient's bowel was patent from the ostomy site to
the rectum. Further discussion will be made with the
surgical team concerning potential intervention.
2. DUODENAL ULCERS: Since the patient had a partial small
bowel obstruction and was made NPO. The patient's regimen
for Helicobacter pylori eradication was switched to
intravenous Protonix, intravenous azithromycin and
intravenous Flagyl. Once the patient is able to take po's
again, this regimen can be switched to a po antibiotic
regimen. The patient's hematocrit remained stable at around
29 to 30 at the time of this discharge summary.
3. INFECTIOUS DISEASE: Infectious disease consult was asked
to asses the duration of patient's treatment with
Staphylococcus epidermitis bacteremia as the cultures that
grew the Staphylococcus epidermitis were drawn from the
patient's right IJ catheter. The patient had been receiving
vancomycin therapy since the beginning of his
hospitalization. Currently, there are plans to consider
removal of the triple lumen catheter once decision for
surgery had been finalized and a PICC line for additional
access had been placed. At that point, decision for
continuation of vancomycin therapy will be made pending.
4. ZOSTER: The patient was noted to have fascicular lesions
across the right upper back underneath the shoulder blade.
He was ambulating with a direct fluorescent antibody test and
found to be positive for varicella zoster. The patient was
then started on intravenous acyclovir at 10 mg per kg per day
for a total of a 7 day course.
5. HEPATIC: Per the attending, the patient's previous
primary care physician remarked that he had a previous CT in
[**2161-4-1**] which showed a small low density in the right
lower lobe that was unchanged since [**2159**].
6. PSYCHIATRIC: The patient was noted to be somewhat
depressed during his admission and was restarted on his
Ritalin therapy. The patient was also involved with social
work and that chaplaincy.
DISCHARGE DIAGNOSES:
1. Duodenal ulcers
2. Helicobacter pylori infection
3. Partial small bowel obstruction
4. Zoster
5. Depression
The remainder of the [**Hospital 228**] hospital course and discharge
medications will be enumerated in a discharge summary
addendum.
[**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**]
Dictated By:[**Name8 (MD) 23851**]
MEDQUIST36
D: [**2164-5-31**] 23:31
T: [**2164-6-1**] 09:09
JOB#: [**Job Number 34683**]
ICD9 Codes: 0389, 2762, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4480
} | Medical Text: Admission Date: [**2170-3-13**] Discharge Date: [**2170-3-17**]
Date of Birth: [**2170-3-13**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 23325**] was a full-term newborn evaluated
in triage after birth because her mother had had an
intrapartum fever. The infant was sent to the Neonatal
Intensive Care Unit at the request of Dr. [**Last Name (STitle) **], the
obstetrician. The baby was [**Name2 (NI) **] at 40-4/7 weeks to a
31-year-old gravida 1 mother who was A+, antibody negative,
GBS negative, hepatitis B surface antigen negative, RPR
nonreactive. The prenatal care had been benign. The mother
was admitted in labor. During labor she had a maximum
temperature of 101 that occurred an hour before delivery. No
antibiotic prophylaxis was used. She then proceeded to have
a stat cesarean section for a nonreassuring fetal heart
pattern that turned out to be a 20% abruption. The infant
was delivered and had Apgar scores of 8 at one minute and 9
at five minutes. Because of the maternal fever the infant
was sent to the Neonatal Intensive Care Unit for triage
evaluation. The initial physical examination was remarkable
only for a somewhat pale infant; otherwise the vital signs
were intact and the infant had a normal examination.
Because of the maternal fever and the initial pallor, a
decision was made to begin antibiotics presumptively for risk
of infection. Ampicillin and gentamicin were started. In
addition, the infant was given a normal saline bolus to
support intravascular volume because of the suspicion of a
nuchal cord. In retrospect, it was probably related to the
maternal abruption.
The infant was released to the newborn nursery with a
Hep-Lock in place. The following afternoon on [**2170-3-14**], the
blood culture turned positive for what has subsequently been
proven to be group B beta streptococcus. The infant returned
to the Neonatal Intensive Care Unit for a repeat blood
culture and for a lumbar puncture. The first lumbar puncture
had inconclusive results because of blood contamination;
specifically, there were 84 white blood cells with 19,680 red
cells. Because of the ambiguity of these results, a lumbar
puncture was repeated and the second lumbar puncture had 436
red cells with one white cell. A repeat blood culture was
also done. The infant was observed and found to be
completely stable and was therefore returned to the newborn
nursery to complete the course of antibiotics. It was
intended to complete a seven-day course. The antibiotics
were changed from the initial ampicillin and gentamicin to
penicillin G at a dose of 200,000 mg per kg per day, or
specifically, 250,000 IU, intravenously every eight hours.
The infant remained in the newborn nursery from [**2170-3-15**] to
[**2170-3-17**]. On that date the parents requested a transfer to
[**Hospital6 4620**] under the care of their primary
pediatrician, Dr. [**Last Name (STitle) 40493**]. Arrangements were made with the
parents and with Dr. [**Last Name (STitle) 40493**], and with [**Hospital6 27253**] to accept this patient. With all in agreement and
assessing the infant as at low risk for release to parents
for the transfer to [**Hospital6 4620**], she was
discharged with Hep-Lock in place and a copy of the medical
record. The parents then drove her to [**Hospital6 27253**] where she was admitted under the care of Dr.
[**Last Name (STitle) 40493**].
REVIEW OF SYSTEMS: There were only a few other pertinent
details. Specifically, she passed her routine hearing screen
and her state laboratory screen was sent on [**2170-3-15**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged to parents with the
intention that they drive her to [**Hospital6 4620**].
A call received from the receiving pediatrician at [**Hospital6 4874**] confirmed that they did, in fact, arrive.
CARE RECOMMENDATIONS:
A. Feeds: The infant was ad lib breast-feeding at discharge.
B. Medications: Penicillin G 250,000 IU intravenously every
eight hours.
C. Newborn state screening status: Sent on [**2170-3-15**].
D. Immunizations received: I do not have the chart at this
time to state whether the vaccine was given; that should be
on the details from [**Hospital6 4620**] discharge.
FOLLOW-UP APPOINTMENTS RECOMMENDED: The infant will be at
continued hospitalization for the balance of a seven-day
treatment course of penicillin.
DISCHARGE DIAGNOSES:
1. Term newborn female.
2. Beta streptococcus bacteremia.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) 40494**] [**Name (STitle) 40493**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**]
Dictated By:[**Last Name (NamePattern1) 40495**]
MEDQUIST36
D: [**2170-3-18**] 08:58
T: [**2170-3-20**] 11:12
JOB#: [**Job Number 40496**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4481
} | Medical Text: Admission Date: [**2138-10-3**] Discharge Date: [**2138-10-5**]
Date of Birth: [**2138-10-3**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] was born at 38 and
2/7 weeks gestation by a planned repeat cesarean section. The
mother is a 28-year-old gravida 4, para 3 (now 4) woman. Her
prenatal screens are blood type A+, antibody negative,
rubella immune, RPR nonreactive, hepatitis surface antigen
negative and group B strep positive. This pregnancy was
uncomplicated. The mother does have a history 10 years ago of
a positive PPD test and was treated with INH for 6 months.
This infant emerged vigorous. Apgar's were 8 at one minute
and 9 at five minutes. He did develop respiratory distress,
and so was admitted to the newborn ICU. His birth weight was
2800 grams, his birth length was 46.5 cm, and his birth head
circumference was 34.5 cm.
PHYSICAL EXAMINATION ON ADMISSION: Revealed a vigorous,
nondysmorphic, term infant. Anterior fontanelle open, flat.
Positive red reflex. Palate intact. Neck supple and without
masses. Mongolian spots on buttocks. Mild intercostal
retractions, grunting and intermittent flaring. Heart was
regular in rate and rhythm. No murmur. Pink and well
perfused. Abdomen soft, nontender, nondistended. A 3-vessel
umbilical cord. A small hair tuft noted at base of spine. No
dimple. Age-appropriate tone and reflexes.
NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS:
1. RESPIRATORY STATUS: He required nasal cannula oxygen for
4 hours when he was then weaned to room air, where he has
remained throughout the remainder of his NICU stay. He
had an arterial blood gas with a pH of 7.36, a pCO2 of
44, a pO2 of 50, bicarbonate of 26, and a base deficit of
0. He continued to be mildly tachypneic and have an
increased work of breathing with feeds until
approximately 24 hours of age when this distress
resolved. He remains in room air. No episodes of apnea of
bradycardia or desaturation.
1. CARDIOVASCULAR STATUS: He has remained normotensive
throughout his NICU stay. He has a heart with regular
rate and rhythm. No murmur. He is pink and well perfused.
He has a quiet precordium and present femoral pulses.
1. NUTRITION: Enteral feeds were begun at approximately 8
hours of life and advanced without difficulty to full
volume feeding. He is breast feeding and supplementing
with formula until mother's milk supply is established.
He has remained euglycemic during his NICU stay.
1. HEMATOLOGY: The infant has received no blood product
transfusions. His hematocrit on admission was 40.6. His
platelet count was 226,000.
1. INFECTIOUS DISEASE STATUS: At the time of admission he
had a blood culture drawn which remains negative at the
time of transfer. He had a white blood cell count of 10.1
with a differential of 63 poly's and 1 band. He received
no antibiotic therapy during his NICU stay.
1. AUDIOLOGY: Hearing screening has not yet been performed
and is recommended prior to discharge.
1. PSYCHOSOCIAL: The family has been involved in the
infant's care during his NICU stay.
CONDITION ON DISCHARGE: He is discharged in good condition.
DISCHARGE DISPOSITION: He is transferred to the newborn
nursery.
NAME OF PRIMARY CARE PEDIATRICIAN: His primary pediatric
care provider will be Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38832**] of [**Hospital1 69290**], [**Location (un) 686**], [**Numeric Identifier 12201**]; telephone number ([**Telephone/Fax (1) 69291**].
RECOMMENDATIONS AFTER DISCHARGE:
1. Feeding: Breast feeding with supplementation until
mother's milk supply is established.
2. The infant is discharged on no medications.
3. The infant does not meet the criteria for a car seat
screening test.
4. State newborn screening should be sent on day of life #3.
5. He has received no immunizations.
6. A bilirubin test should be done also on day of life #3.
DISCHARGE DIAGNOSES:
1. Status post transitional respiratory distress.
2. Sepsis ruled out.
3. Term male newborn.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2138-10-5**] 01:34:25
T: [**2138-10-5**] 09:30:54
Job#: [**Job Number 69292**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4482
} | Medical Text: Admission Date: [**2109-7-24**] Discharge Date: [**2109-7-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Acute shortness of breath, transfer for OSH intubated and
sedated
Major Surgical or Invasive Procedure:
S/P brief intubation/ventilation
History of Present Illness:
Pt is a [**Age over 90 **] yo male with h/o of chronic a fib, nonischemic
dilated cardiomyopathy, EF 25-30%, multivalvular disease
transferred from [**Location (un) 620**] after becoming hypoxic and intubated
for mangement of CHF. Pt was meeting with his family this AM
regarding nursing home placement for his sister at which time he
became very upset and started having SOB. Per his son he became
acutely SOB and had some chest pain. His baseline weight from
[**2109-7-18**] was 147 lbs. as which time he was seen by Dr. [**Last Name (STitle) **] and
was felt to be euvolemic.
He was given lasix 60 IV and started on nitro drip. He failed a
trial of bipap at OSH so he was intubated and sedated. EKG
showed A fib, rate 71, indeterminate axis, LBBB similar to
previous
Past Medical History:
1. congestive heart failure, non-ischemic CM, EF 25-30% with +2
AI, +3 MR, +3 TR (echo [**3-/2108**])
2. paroxysmal atrial fibrillation
3. hypertension
4. BPH
5. spinal stenosis
6. CRI baseline cre 1.2-1.3
Social History:
lives alone, splitting his time between [**Location (un) 86**] and [**Location (un) **],
retired law professor. Family is very involved.
no tob, EtoH
Family History:
non-contributory
Physical Exam:
Vitals: T 97.6 HR 71 RR 28 BP 108/61
HEENT: pt intubated and sedated, elevated JVP
CV: irregular rate, no murmurs appreciated
Pulm: diffuse crackles bilaterally
Abd: normal BS, soft, NT/ND
ext: trace edema, 1+ DP and PT
pulses
Neuro: intubated and sedated
Pertinent Results:
[**2109-7-24**] 04:15PM BLOOD WBC-10.7 RBC-3.54* Hgb-11.6* Hct-34.8*
MCV-98 MCH-32.9* MCHC-33.5 RDW-14.2 Plt Ct-214
[**2109-7-25**] 04:00PM BLOOD Hct-31.4*
[**2109-7-26**] 07:05AM BLOOD WBC-8.5 RBC-3.09* Hgb-10.1* Hct-29.5*
MCV-95 MCH-32.7* MCHC-34.3 RDW-14.0 Plt Ct-224
[**2109-7-24**] 04:15PM BLOOD PT-19.5* PTT-29.5 INR(PT)-2.5
[**2109-7-25**] 04:20AM BLOOD PT-19.9* PTT-32.1 INR(PT)-2.6
[**2109-7-26**] 07:05AM BLOOD Plt Ct-224
[**2109-7-24**] 04:15PM BLOOD Glucose-179* UreaN-29* Creat-1.8* Na-135
K-6.6* Cl-99 HCO3-21* AnGap-22*
[**2109-7-25**] 05:00PM BLOOD Glucose-193* UreaN-32* Creat-1.6* Na-134
K-4.0 Cl-97 HCO3-24 AnGap-17
[**2109-7-26**] 07:05AM BLOOD Glucose-94 UreaN-29* Creat-1.4* Na-134
K-3.6 Cl-100 HCO3-22 AnGap-16
[**2109-7-25**] 12:08AM BLOOD CK(CPK)-66
[**2109-7-25**] 04:20AM BLOOD CK(CPK)-57
[**2109-7-24**] 04:15PM BLOOD cTropnT-<0.01
[**2109-7-25**] 12:08AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2109-7-25**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2109-7-24**] 05:05PM BLOOD Cholest-122
[**2109-7-26**] 07:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1
[**2109-7-24**] 05:05PM BLOOD Triglyc-29 HDL-65 CHOL/HD-1.9 LDLcalc-51
[**2109-7-24**] 05:05PM BLOOD Digoxin-1.5
[**2109-7-24**] 09:41PM BLOOD Type-ART Tidal V-600 PEEP-10 FiO2-60
pO2-188* pCO2-31* pH-7.51* calHCO3-26 Base XS-2
Intubat-INTUBATED
[**2109-7-24**] 05:32PM BLOOD K-4.8
[**2109-7-24**]
CXR: The ET tube has been advanced and is in optimal position
now at about 4.5 cm from the carina. Note that the lower lung
fields are not included in the film. Persistent moderate
cardiomegaly with asymmetric pulmonary edema, more on the right
than left.
[**2109-7-25**]
CXR: There is moderate stable cardiomegaly. Atherosclerotic
calcification is noted in the aortic knob and the descending
aorta. Scarring is again noted at the right apex. Right basilar
atelectasis is noted along with left lower lobe atelectasis.
There is no pulmonary edema.
NG tube tip projects beyond the film and appears to lie in the
stomach.
[**2109-7-26**]
CXR: 1. Interval improvement of pulmonary edema.
2. Unchanged bibasilar atelectasis.
3. No evidence of pneumothorax.
Brief Hospital Course:
[**Age over 90 **] yo male with nonischemic cardiomyopathy, EF 25-30% admitted
with acute SOB and CP s/p intubation for hypoxia likely due to
flash pulmonary edema in the setting of hypertension
1. CHF: On admission the patient was intubated an sedated he was
diuresed and was weaned off the ventilator by the morning after
admission. There was significant improvement in his respiratory
status and in his pulmonary edema on chest x-ray. He was
discharged on his original home medication regimen with the
addition of lisinopril and will follow up with his cardiologist
on [**2109-8-7**].
.
2. A.fib: Patient remained hemodynamically stable in stable in a
fib. He was continue on digoxin and Coreg and will follow up
with his cardiologist.
3. Chest pain: Patient had no EKG changes suggestive of MI. His
cardiac enzymes were negative. This was most likely secondary
to his acute distress and flash pulmonary edema.
4. BPH: He had no issues during this hospitalization and will
continue finasteride and tamsulosin.
5. Hypertension: Patient was hypotensive on admission. His
antihypertensives were added back as his blood pressure allowed
and he was well controlled during his admission. He was
discharged on Coreg and lisinopril.
Medications on Admission:
MVI
coreg 6.25 mg po BID
Warfarin 2 mg 6 days per week, 1 mg on saturday
Simvastatin 5 mg po qd
Terozosin 1 mg po qd
TRazadone 50 mg po QHS,
Digoxin 0.125 mg po qd
lasix 60 mg po qday
Finasteride 5 mg qd
Discharge Medications:
1. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: One (1)
spray Translingual once as needed for chest pain: to be used
only for chest pain or shortness of breath.
Disp:*30 cc* Refills:*0*
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO Q
M,TU,W,TH,FR,SUN (): 1mg on Sat.
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QOD ().
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CHF exacerbation
CHF EF 25-30%
Dilated cardiomyopathy
Atrial fibrillation
BPH
Hypertension
Spinal stenosis
Decreased hearing
CRI
Discharge Condition:
Stable
Discharge Instructions:
Return to care if you have shortness of breath, chest pain,
weight gain more than 3 pounds.
Take all medications as prescribed
You will now take digoxin every other day. Have your
cardiologist check a level at next visit.
You should have INR checked within 1 week.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 3670**]: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2109-8-7**] 10:30
ICD9 Codes: 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4483
} | Medical Text: Admission Date: [**2108-11-12**] Discharge Date: [**2108-11-17**]
Date of Birth: [**2075-1-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 33-year-old female
with history of left breast cancer. Had chemotherapy.
PAST MEDICAL HISTORY: Has a past medical history of
depression and she also presented with a need of prophylactic
mastectomy due to high risk on her right side. She had
previous surgery on her left breast with biopsy. She has
wisdom teeth removed and a molar removed, and she has had a
history of laparoscopic surgery.
ALLERGIES: Erythromycin.
MEDICATIONS: The medication that she takes on a daily basis
was Celexa.
PHYSICAL EXAMINATION: She was otherwise in good health. She
was supple, no nodes were noted on HEENT examination. Her
chest was clear, S1, S2. There was a noted nipple inversion
and a large mass was noted on the left.
IMPRESSION: Left breast cancer.
PLAN: Bilateral mastectomies with left axillary dissection.
HOSPITAL COURSE: After the patient was identified, was taken
to the operating room, and a combined procedure with Dr.
[**Last Name (STitle) 364**], please see operative dictation. However, [**Location (un) **] and
[**Doctor Last Name 13797**] left [**Last Name (un) 5884**] free flap was performed in which the
vascular anastomosis was hooked into the LIMA and a right
pedicle TRAM flap was performed. The patient tolerated the
procedure well. Five hundred cc estimated blood loss, IV
fluids 5400, urine output during the case was 690 cc.
Patient was stable. Discharged to the Surgical ICU, where
she stayed for 48 hours with frequent flap checks.
Her postoperative hematocrit on day #1 was 28. However,
after continued the Doppler checks on the left flap and the
capillary refill on the right skin panel were extremely
adequate throughout the duration of her stay in the ICU.
However, the patient remained with persistent tachycardia.
She was bolused and she was given 1 unit of packed red blood
cells.
She continued to do well in the postoperative course and was
transferred after 48 hours to the floor. Some pain control
issues were present once the patient was switched over from
IV pain medications and switched to oral. However, after a
minimal amount of time, the patient's pain regimen was
stratified and patient continued to do well with oral pain
medications. Her diet was advanced as tolerated, and patient
was HEP locked as far as her IV goes. Her Foley was removed
and she was ambulating frequently on the floor. However,
throughout the course of this, her flap continued to remain
viable being her pedicle TRAM and her free flap remained with
good Doppler signal. Good skin color was noted on the skin
paddles.
Patient continued to ambulate under the service of Dr.
[**Last Name (STitle) 364**], general surgeon attending, Medicine consult was
called for persistent tachycardia. At that juncture, the
consultant recommended that an EKG be performed to rule out a
supraventricular tachycardia. EKG was performed and it was
determined that the patient was in sinus tachycardia, and it
was deemed that this patient was improving clinically as her
hematocrit did come up to 25. After 1 unit, she had come up
from a hematocrit of 23. Patient continued to improve over
the next several days, and it was decided that the patient
had met criteria for discharge. Patient was given all
instructions and all questions were answered prior to
discharge.
DISCHARGE MEDICATIONS:
1. Aspirin.
2. Keflex.
3. Oral pain control.
DISCHARGE INSTRUCTIONS: Patient was given strict
instructions to followup. She was given a visiting nursing
services in which to follow her drain, and patient will be
seen in the office next week by Dr. [**First Name (STitle) **] in order to have
drains removed and to have her wounds assessed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Last Name (NamePattern1) 740**]
MEDQUIST36
D: [**2108-11-16**] 19:28
T: [**2108-11-17**] 10:14
JOB#: [**Job Number 25048**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4484
} | Medical Text: Admission Date: [**2121-9-28**] Discharge Date: [**2121-10-5**]
Service:
THIS DICTATION WILL COVER THE DATES OF ADMISSION FROM
[**2121-9-28**] TO [**2121-10-5**]. PLEASE SEE DISCHARGE SUMMARY
ADDENDUM FOR THE REST OF THE ADMISSION HISTORY.
CHIEF COMPLAINT: Syncope.
HISTORY OF THE PRESENT ILLNESS: This is an 84-year-old woman
with diabetes mellitus, history of prior myocardial
infarction, numerous syncopal episodes in past of unknown
etiology, who noticed increased fatigue and decreased PO
intake over the past two to three weeks. The patient fell
two times today on a carpeted floor, but the patient did not
hit her head. She did lose consciousness for a short period.
The patient believes she hit her right hip and lip. There
was no history of chest pain or shortness of breath,
dizziness, vertigo, or palpitations. The patient attends a
physical therapy program every week, where she does note
bilateral dull shoulder pain, which was different from her
anginal pain, previously, which she experienced with mild
physical activity. Per the patient, she does not note any
decreased exercise tolerance or any episodes of paroxysmal
nocturnal dyspnea in the recent week. The patient does not
have any baseline orthopnea. The patient has not noticed any
increase in peripheral edema or weight gain over the past few
days.
HISTORY OF THE PRESENT ILLNESS:
1. Coronary artery disease, myocardial infarction in [**2115**]
with cardiac catheterization and RC stent in [**2115-6-15**],
[**8-/2119**] catheterization, RCA with 40% stenotic in the
midportion, 30% distally, LAD 70% mid portion stenosis, D1
70% to 80% stenosis, left circumflex diffusely diseased and
completely occluded beyond the first obtuse marginal branch.
Moderate MR, moderate pulmonary hypertension.
2. Congestive heart failure. Echocardiogram, [**3-/2121**]
revealed ejection fraction of 20% to 25%. Severe global left
ventricular hypokinesis, trace MR, left wall thickness
normal. Echocardiogram, [**2121-1-14**], EF 10% to 15%,
moderate MR, left ventricular hypokinesis. Borderline
pulmonary systolic hypertension. Echocardiogram,
[**Month (only) 1096**] [**2121**], ejection fraction 30% to 35% no LVH, severe
hypokinesis to akinesis of basal inferior septum and inferior
posterior wall. Remaining segments were low normal to mildly
hypokinetic. Mild MR. Persantine stress test: [**2119-1-14**], no anginal symptoms, no EKG changes. Partially
reversible inferolateral perfusion defect with left inferior
wall involvement on a prior study.
3. Diabetes mellitus.
4. Orthostatic hypertension.
5. Left breast cancer, status post lumpectomy.
6. Gastroesophageal reflux disease.
7. Hypothyroidism.
8. Bilateral cataract status post surgery.
9. Polymyalgia rheumatica.
MEDICATIONS ON ADMISSION:
1. Prednisone 2.5 mg q.a.m.
2. [**Doctor First Name **] p.r.n.
3. Protonix 40 mg q.a.m.
4. Aspirin 325 mg PO q.d.
5. Detrol 4 mg PM.
6. Synthroid 0.125 mg PO q.d.
7. Neurontin 300 mg b.i.d.
8. Prozac 20 mg q.a.m.
9. Digoxin 0.125 mg q.a.m.
10. Glucophage 500 mg t.i.d.
11. Multivitamin.
12. Tums, one tablet t.i.d.
13. Kayexalate q.other day.
14. Regular insulin sliding scale 25 units AM, and 20 units
PM NPH insulin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient was born in [**Hospital1 8**] and
assisted by home health aid. The patient is able to do most
of the activities of daily living without difficulty at
baseline. No alcohol, smoking, or drug use in the past.
FAMILY HISTORY: Father died of prostate cancer. No family
history of premature coronary artery disease or temporal
arteritis/polymyalgia rheumatica.
PHYSICAL EXAMINATION: Examination, upon presentation,
revealed the vital signs of 112/44, heart rate 53,
respirations 99% on two liters. Respirations 22. GENERAL:
The patient is a pleasant female with no apparent disease.
HEENT: Bruise on upper lip, no JVD, mucous membranes moist.
Pallor under eye lids. CARDIAC: Normal S1 and S2. No
murmurs, rubs, or gallops. HEART: Heart sounds were
distant. LUNGS: Lungs revealed crackles [**2-16**] of the way up.
There was good air movement. ABDOMEN: Positive bowel
sounds, soft, nontender, nondistended, no rebound or
guarding. EXTREMITIES: No edema, 1+ dorsalis pedis pulses
bilaterally.
LABORATORY DATA: Labs upon admission revealed the following:
White blood cell count 6.7, hematocrit 27.2, platelet count
230,000, PT 13.3, PTT 22.6, INR 1.2, sodium 134, potassium
6.2, which was hemolyzed. Repeat potassium was 5.8.
Chloride 100, bicarbonate 20, BUN 37, creatinine 1.8, glucose
175, urinalysis negative. CK 215, MB 12, troponin 47.7.
Chest x-ray revealed congestive heart failure, left
ventricular enlargement. CT of the head revealed no
hemorrhage, no mass effect, no infarct. EKG revealed old
left bundle branch block, ST segment elevation only about
1 mm elevations in V2 through V5.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name **]
Service, where she ruled in for myocardial infarction by CKs
and troponins. The patient was held off the carvedilol
secondary to active congestive heart failure. The patient
received one unit of packed red blood cells due to anemia.
Unfortunately, this worsened the congestive heart failure
with crackles remaining 2/3rds of the way up, even after IV
Lasix dose. The patient was also held on her ACE inhibitor
since the creatinine was high and potassium was high. Renal
consultation was curbsided and it turns out that the patient
had hypoaldosteronism in the past, which explains her
chronically elevated levels of potassium and three times a
week of Kayexalate. The patient was monitored on telemetry
and did quite well. The patient continued to remain on
heparin drip, and the patient was scheduled for
catheterization after the weekend. Unfortunately, the
patient acutely decompensated. On [**2121-9-30**], the patient had
an episode of atrial fibrillation, which is new. The atrial
fibrillation was accompanied by systolic blood pressure
dropping into the 70s and heart rate jumping into the 120s.
The patient also noted an episode of right shoulder pain at
that time and EKG revealing atrial fibrillation and
rate-related ST segment changes. The patient could not be
given beta blocker or Cardizem due to decreased blood
pressure. The patient was given two fluid boluses of 250
normal saline, which resulted in systolic blood pressure
coming up to 85 and decreased heart rate to 95. The
patient's pain resolved with sublingual nitroglycerin. It
was decided that the patient should go to the cardiac
catheterization laboratory for elective cardioversion due to
atrial fibrillation resulting in cardiovascular compromise.
The patient was transferred up to the cardiac catheterization
laboratory for cardioversion at this time. While in the
cardiac catheterization laboratory, the patient underwent
cardioversion, which resulted in temporary normal sinus
rhythm. The patient underwent cardiac catheterization,
during which time RCA stent was placed. The patient, during
the cardiac catheterization, had runs of V tachycardia, which
converted by defibrillation. The patient was intubated. The
patient had a balloon pump placed. The patient was placed on
Amiodarone, Lidocaine, as well as pressors. The patient was
transferred to the coronary care unit for further management.
Dr. [**Last Name (STitle) 284**] [**Name (NI) 653**] the family at that time to discuss
further management options and interventions.
The patient remained in the coronary care unit for three
days, where she was given stress dose steroids, secondary to
PMR. She was continued on heparin since she had ruled in for
a second MI due to that brief episode of chest pain. The
patient was also noted ....................and was placed on
insulin drip with glucoses running greater than 400,
accompanied by anion gap. The patient's hematocrit was low,
and the patient was transfused two units of packed red blood
cells. Urine culture at that time was also found be positive
as was the chest x-ray with a question of left lobe
infiltrate. The patient was started on Levofloxacin and
Flagyl for a ten-day course due to the possibility of
aspiration pneumonia with the intubation, as well as positive
urine culture for E. coli. The patient was changed over to
PO Amiodarone after two days and she was continued on 400 mg
t.i.d. for the first two days and 400 mg b.i.d. thereafter.
The Digoxin was restarted for better rate control. It was
suggested that the patient's ACE and beta blocker were to be
restarted, but she remained in CHF and the beta blocker was
deferred. IV Vancomycin was also started, while she was in
the coronary care unit for one out of four bottles positive
for gram-positive cocci, which was possibly thought to be a
contaminate, but secondary to the presence of central line.
This medication was discontinued. During all these
interventions, the patient was positive six liters of fluid,
but diuresed approximately two liters with crackles remaining
half way up her lung fields, prior to discharge from the
coronary care unit.
Of note, on the day prior to discharge from coronary care
unit, the patient had an echocardiogram done, which revealed
severely depressed LV systolic function, ejection fraction of
20% to 25%, anteroseptal inferior hypokinesis with
hypokinesis elsewhere. Mild-to-moderate MR. Moderate
pulmonary hypertension. The patient was thought stable at
this point to be transferred to the [**Hospital Unit Name **] Service. She was
taken off her pressors. She was continued on the Amiodarone
and antibiotics. She was transferred back to [**Hospital Unit Name **].
While on the [**Hospital Unit Name **] floor, the patient was continued on
Amiodarone and Digoxin for the atrial fibrillation. On the
second day, status post coronary care unit stay, the Digoxin
was discontinued, secondary to heart rates around 56 since
she was on Amiodarone, Digoxin, and beta blocker at this
time. The beta-blocker was held secondary to acute
congestive heart failure. The ACE inhibitor was also held
due to high creatinine and potassium and hypokalemia. The
patient was diuresed with Lasix 40 mg b.i.d. to try to keep
her negative one liter a day with improvement in the
congestive heart failure. The patient had been transfused
three units of packed red blood cells during the stay at [**Hospital1 1444**] at this time, which was
worrisome. The patient was to have all stools guaiac
tested. Hemolysis labs were performed, which were not
consistent with acute hemolysis, only an LDH, which had been
elevated. The patient was placed on iron, since she has been
on iron in the past. Iron stains were not performed since
she had received three units of packed red blood cells and
this would confound the results of iron studies.
The patient was continued on her gastrointestinal prophylaxis
and Reglan for nausea, from an Infectious Disease standpoint.
Levofloxacin and Flagyl were continued for ten days as PO.
Surveillance cultures were taken and pending results of the
cultures, the patient was to have the Vancomycin discontinued
or PICC line placed. The patient also had her code status
changed to DNR/DNI, after a long discussion with the family,
but at the time that I left the service it was quite
uncertain if she still wished pressors to be used and this
issue was to be further discussed with the family and
decision was to be made by the time of discharge. Of note,
the patient was markedly depressed after her coronary care
unit stay. At one time during the coronary care unit she
said "I don't want to look like this, I'm in a lot of pain."
Measures were ensured to make sure that her pain control was
adequate. The patient was also referred for social worker
consultation to discuss some of her depression and the recent
myocardial infarction. The patient was also to be followed
up by the Department of Physical Therapy for evaluation on
Monday to see if her new MI and numerous interventions would
prevent her from returning back to her independent lifestyle.
Please see discharge summary addendum for the rest of this
patient's admission history.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] t.m.d [**MD Number(1) 4786**]
Dictated By:[**Name8 (MD) 4712**]
MEDQUIST36
D: [**2121-10-5**] 12:44
T: [**2121-10-9**] 11:26
JOB#: [**Job Number 4976**]
ICD9 Codes: 4280, 2767, 5070, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4485
} | Medical Text: Unit No: [**Numeric Identifier 63462**]
Admission Date: [**2108-8-29**]
Discharge Date: [**2108-9-2**]
Date of Birth: [**2108-8-29**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 63463**] is a 35-3/7 week gestation
female transferred to the newborn intensive care for mild
respiratory distress.
Perinatal history for this primigravida mother was notable
only for GBS unknown maternal status, blood type O negative,
prenatally diagnosed 2-vessel cord, AFI of 3 prompting
induction. Nonreactive fetal heart tracing prompted cesarean
section with artificial rupture of membranes at delivery and
no other perinatal risk factors for sepsis.
PHYSICAL EXAMINATION ON ADMISSION: Two vessel cord now with
no increased work of breathing and initially was noted to
have grunting, flaring and retracting in the newborn nursery.
She is well-appearing, non-dysmorphic. Anterior fontanelle is
soft and flat. Palate is intact. Regular rate and rhythm
without murmur. There were 2+ peripheral pulses including
femorals. Abdomen was benign without HSM. No masses, normal
female external genitalia for gestational age, normal back
and extremities. Skin - pink, well-perfused, alert and
responsive with appropriate tone and strength.
REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant remained in room air with saturations greater than 95.
Respiratory rate was 40s-60s. The respiratory distress
resolved without intervention and there were no further
issues.
Cardiovascular: No murmur, baseline heart rate 130s-140s,
blood pressure 50s/40s with a mean of 45.
Fluids, Electrolytes and Nutrition: Birth weight was 2485.
Transfer weight was 2430, AGA. Infant ad lib feeding without
needing gavage. Infant is taking breast milk or Enfamil 20 ad
lib, taking in greater than 60 ml/kg/day, voiding, stooling
and did not require electrolytes during this admission.
Bilirubin was not done during the admission. The baby did not
appear jaundiced.
Hematology: Blood type was not required nor were blood
products during this admission.
Infectious Disease: There were no risk factors for infection
other than those stated above. The baby did not require a CBC
or blood culture and did not require any antibiotics.
Neurology: The baby was appropriate for gestational age.
Sensory: Audiology screening not done at time of transfer.
Ophthalmology: Infant greater than 32 weeks. No exam required
at this time.
Psychosocial: Mom looks forward to [**Known lastname 41356**] returning to the
newborn nursery.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: To newborn nursery with mom.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], [**Location (un) 5344**], [**State 350**].
CARE RECOMMENDATION: Continue breastfeeding or ad lib
feeding Enfamil 20 with iron or breast milk. Medications -
none at time of transfer. Car seat position screening has not
been performed yet. State newborn screen status will be due
on day of life 3. Immunizations received - none at time of
transfer. Immunizations recommended - Synergist RSV
prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**]
for infants who meet any of the following 3 criteria - i)
born at less than 32 weeks; ii) born between 32 and 35 weeks
with 2 of the following - day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings; or iii) with chronic
lung disease. Influenza immunization is recommended annually
in the fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home caregivers. Follow-up
appointments with primary care physician per routine. Follow-
up appointments scheduled and recommended as above with
primary care pediatrician.
DISCHARGE DIAGNOSIS: A 35-3/7 week premature female, 2-
vessel cord, status post mild transitional respiratory
distress which has resolved.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 50-ABP
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2108-9-2**] 05:51:21
T: [**2108-9-2**] 06:26:04
Job#: [**Job Number 63464**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4486
} | Medical Text: Admission Date: [**2177-2-4**] Discharge Date: [**2177-3-5**]
Date of Birth: [**2147-8-13**] Sex: F
Service: UROLOGY
Allergies:
Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril /
Heparin Agents
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Bilateral renal masses
Major Surgical or Invasive Procedure:
Bilateral laparoscopic radical nephrectomies, ex-lap and
evacuation of hematoma
History of Present Illness:
29yF with ESRD secondary to SLE s/p failed renal transplant in
[**2174**] now with bilateral renal masses noted on MRI. Consultations
with radiology, transplant nephrology, and urology felt that the
primary concern was need for tissue diagnosis and removal to
facilitate relisting as transplant candidate. The least morbid
and most efficient approach was considered laparoscopic
bilateral nephrectomies.
Past Medical History:
1. SLE diagnosed [**2166**] complicated by lupus/nephritis, anemia,
serositis and ascites
2. End stage renal disease secondary to lupus, HD T/Th/Sat
3. History of VSD s/p corrective surgery, age 13
4. Hypertension
5. ITP
6. MSSA endocarditis
7. Sickle cell trait
8. s/p left oophorectomy related to IUD associated infection
9. Restrictve lung disease noted on PFTs [**2166**]. In [**2173**], chest CT
with diffuse ground glass opacities.
10. GERD
11. s/p cadaveric renal transplant on [**8-/2175**] complicated by
rejection and capsule rupture 11/[**2174**].
12. Right pelvic abscess s/p TAH/RSO
13. B/L renal solid masses
Social History:
No smoking, occasional alcohol, no drug use. Lives at home with
husband and son. Not currently employed.
Family History:
NC
Physical Exam:
98.6 84 130/72 18 94%RA
GEN: AAOx3, NAD
CHEST: CTAB
CARDIOVASCULAR: RRR, 2-3/6 systolic murmur.
Abd: soft, ND, min TTP
Incision: c/d/i with steri strips
Ext: no c/c/e
Pertinent Results:
[**2177-2-4**] 03:36PM GLUCOSE-83 UREA N-46* CREAT-11.2*# SODIUM-137
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-16
[**2177-2-4**] 03:36PM CALCIUM-8.5 MAGNESIUM-2.6
[**2177-2-4**] 03:36PM WBC-10.6# RBC-2.99* HGB-9.0* HCT-28.3* MCV-95
MCH-30.0 MCHC-31.7 RDW-21.3*
[**2177-2-4**] 03:36PM PLT COUNT-105*
[**2177-2-4**] 01:59PM TYPE-[**Last Name (un) **] PO2-54* PCO2-45 PH-7.43 TOTAL
CO2-31* BASE XS-4 INTUBATED-INTUBATED
[**2177-2-4**] 01:59PM GLUCOSE-248* LACTATE-3.3* NA+-136 K+-5.3
CL--98*
[**2177-2-4**] 01:59PM HGB-9.2* calcHCT-28
[**2177-2-4**] 01:59PM freeCa-1.19
[**2177-2-4**] 01:09PM TYPE-[**Last Name (un) **] PO2-48* PCO2-45 PH-7.44 TOTAL
CO2-32* BASE XS-5
[**2177-2-4**] 01:09PM GLUCOSE-131* LACTATE-2.4* NA+-138 K+-5.4*
CL--99*
[**2177-2-4**] 01:09PM HGB-10.1* calcHCT-30
[**2177-2-4**] 01:09PM freeCa-1.04*
[**2177-2-4**] 11:10AM TYPE-[**Last Name (un) **] PO2-57* PCO2-53* PH-7.38 TOTAL
CO2-33* BASE XS-4 INTUBATED-INTUBATED
[**2177-2-4**] 11:10AM TYPE-[**Last Name (un) **] PO2-57* PCO2-53* PH-7.38 TOTAL
CO2-33* BASE XS-4 INTUBATED-INTUBATED
[**2177-2-4**] 11:10AM GLUCOSE-147* LACTATE-1.9 NA+-139 K+-5.1
CL--98*
[**2177-2-4**] 11:10AM HGB-10.3* calcHCT-31
[**2177-2-4**] 11:10AM freeCa-1.06*
[**2177-2-4**] 09:16AM TYPE-[**Last Name (un) **] PO2-60* PCO2-45 PH-7.44 TOTAL
CO2-32* BASE XS-5
[**2177-2-4**] 09:16AM GLUCOSE-100 LACTATE-2.0 NA+-140 K+-4.9
CL--97*
[**2177-2-4**] 09:16AM HGB-10.9* calcHCT-33
[**2177-2-4**] 09:16AM freeCa-1.09*
[**2177-2-20**] 04:33AM BLOOD WBC-13.2* RBC-3.60* Hgb-11.2* Hct-32.6*
MCV-91 MCH-31.1 MCHC-34.3 RDW-18.7* Plt Ct-143*
[**2177-2-19**] 09:57AM BLOOD WBC-12.9* RBC-3.99* Hgb-11.9* Hct-37.0
MCV-93 MCH-29.7 MCHC-32.1 RDW-18.2* Plt Ct-104*
[**2177-2-18**] 07:28PM BLOOD WBC-13.0* RBC-3.82* Hgb-11.6* Hct-34.9*
MCV-91 MCH-30.4 MCHC-33.2 RDW-17.8* Plt Ct-72*
[**2177-2-18**] 11:28AM BLOOD WBC-12.0* RBC-3.60* Hgb-11.3* Hct-32.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-17.7* Plt Ct-74*
[**2177-2-18**] 05:15AM BLOOD WBC-11.1* RBC-3.32* Hgb-10.2* Hct-30.5*
MCV-92 MCH-30.7 MCHC-33.4 RDW-17.7* Plt Ct-64*
[**2177-2-17**] 03:15AM BLOOD WBC-8.6 RBC-2.83* Hgb-8.8* Hct-24.9*
MCV-88 MCH-31.2 MCHC-35.5* RDW-17.5* Plt Ct-63*
[**2177-2-16**] 04:13PM BLOOD Hct-24.7*
[**2177-2-16**] 03:04AM BLOOD WBC-7.9 RBC-2.94* Hgb-9.2* Hct-25.5*
MCV-87 MCH-31.2 MCHC-36.0* RDW-17.4* Plt Ct-50*
[**2177-2-15**] 09:48PM BLOOD Hct-24.8*
[**2177-2-15**] 10:30AM BLOOD Hct-24.5*
[**2177-2-14**] 08:45PM BLOOD WBC-10.2 RBC-3.22*# Hgb-9.9*# Hct-27.2*#
MCV-85 MCH-30.7 MCHC-36.3* RDW-16.9* Plt Ct-64*
[**2177-2-14**] 05:29PM BLOOD WBC-9.9 RBC-2.34* Hgb-7.2* Hct-20.0*
MCV-86 MCH-30.9 MCHC-36.0* RDW-18.3* Plt Ct-74*
[**2177-2-14**] 02:35PM BLOOD WBC-10.8 RBC-2.23* Hgb-6.7* Hct-19.2*
MCV-86 MCH-30.2 MCHC-35.1* RDW-19.3* Plt Ct-94*
[**2177-2-14**] 08:53AM BLOOD Hct-18.0*
[**2177-2-14**] 05:38AM BLOOD Hct-21.0* Plt Ct-113*
[**2177-2-14**] 02:01AM BLOOD WBC-15.2*# RBC-2.55* Hgb-7.9* Hct-23.3*
MCV-91 MCH-30.8 MCHC-33.8 RDW-20.9* Plt Ct-109*
[**2177-2-13**] 05:44AM BLOOD WBC-7.6 RBC-3.32* Hgb-10.1* Hct-29.3*
MCV-88 MCH-30.5 MCHC-34.5 RDW-19.6* Plt Ct-85*
[**2177-2-12**] 09:05PM BLOOD Hct-33.0* Plt Ct-85*
[**2177-2-12**] 04:38AM BLOOD WBC-6.4 RBC-3.63* Hgb-11.1* Hct-32.7*
MCV-90 MCH-30.7 MCHC-34.0 RDW-19.2* Plt Ct-90*
[**2177-2-12**] 01:27AM BLOOD WBC-6.6 RBC-3.64* Hgb-10.7* Hct-32.6*
MCV-90 MCH-29.4 MCHC-32.8 RDW-19.2* Plt Ct-100*
[**2177-2-11**] 08:42PM BLOOD WBC-6.7 RBC-3.91* Hgb-11.6* Hct-33.8*
MCV-86 MCH-29.7 MCHC-34.4 RDW-19.2* Plt Ct-75*
[**2177-2-11**] 03:46PM BLOOD WBC-6.9 RBC-3.55* Hgb-10.5* Hct-32.0*
MCV-90 MCH-29.7 MCHC-32.9 RDW-19.3* Plt Ct-76*
[**2177-2-11**] 11:45AM BLOOD WBC-6.0 RBC-3.63* Hgb-11.1* Hct-31.9*
MCV-88 MCH-30.5 MCHC-34.7 RDW-19.3* Plt Ct-104*
[**2177-2-11**] 08:49AM BLOOD Hct-34.1*
[**2177-2-11**] 04:05AM BLOOD WBC-8.2 RBC-3.65* Hgb-10.9* Hct-33.7*
MCV-92 MCH-30.0 MCHC-32.4 RDW-19.2* Plt Ct-86*
[**2177-2-10**] 08:08PM BLOOD WBC-7.8 RBC-3.63* Hgb-11.1* Hct-32.3*
MCV-89 MCH-30.7 MCHC-34.5 RDW-19.4* Plt Ct-68*
[**2177-2-10**] 01:26PM BLOOD WBC-7.2 RBC-3.78* Hgb-11.3* Hct-34.0*
MCV-90 MCH-29.8 MCHC-33.2 RDW-19.0* Plt Ct-75*
[**2177-2-10**] 03:10AM BLOOD WBC-7.9 RBC-3.89* Hgb-11.5* Hct-34.9*
MCV-90 MCH-29.6 MCHC-33.0 RDW-19.0* Plt Ct-68*
[**2177-2-9**] 07:45PM BLOOD Hct-35.3* Plt Ct-73*
[**2177-2-9**] 09:32AM BLOOD Hct-36.6 Plt Ct-73*
[**2177-2-9**] 05:48AM BLOOD WBC-8.5 RBC-3.97* Hgb-11.8* Hct-35.2*
MCV-89 MCH-29.9 MCHC-33.6 RDW-19.3* Plt Ct-82*
[**2177-2-9**] 12:55AM BLOOD WBC-9.0 RBC-3.88* Hgb-11.7* Hct-34.2*
MCV-88 MCH-30.1 MCHC-34.1 RDW-19.1* Plt Ct-78*
[**2177-2-8**] 08:40PM BLOOD WBC-10.2 RBC-4.07* Hgb-12.3 Hct-35.5*
MCV-87 MCH-30.2 MCHC-34.7 RDW-19.1* Plt Ct-76*
[**2177-2-8**] 04:52PM BLOOD WBC-9.3 RBC-4.02* Hgb-12.1 Hct-34.9*
MCV-87 MCH-30.0 MCHC-34.6 RDW-19.0* Plt Ct-85*
[**2177-2-8**] 12:41PM BLOOD WBC-10.8 RBC-4.28 Hgb-12.8 Hct-37.0
MCV-87 MCH-29.8 MCHC-34.4 RDW-19.0* Plt Ct-80*
[**2177-2-8**] 08:49AM BLOOD WBC-8.7 RBC-3.66* Hgb-10.8* Hct-32.0*
MCV-87 MCH-29.5 MCHC-33.8 RDW-19.5* Plt Ct-95*
[**2177-2-8**] 03:18AM BLOOD WBC-7.7 RBC-3.06* Hgb-9.0* Hct-26.1*
MCV-85 MCH-29.3 MCHC-34.4 RDW-20.2* Plt Ct-84*
[**2177-2-7**] 11:55PM BLOOD WBC-7.4 RBC-2.85* Hgb-8.3* Hct-24.5*
MCV-86 MCH-29.0 MCHC-33.8 RDW-19.9* Plt Ct-75*
[**2177-2-7**] 08:28PM BLOOD WBC-7.1 RBC-2.62* Hgb-8.0* Hct-22.5*
MCV-86 MCH-30.3 MCHC-35.3* RDW-20.3* Plt Ct-76*
[**2177-2-7**] 02:01PM BLOOD Hct-23.2*
[**2177-2-7**] 10:25AM BLOOD Hct-25.5*#
[**2177-2-6**] 09:50AM BLOOD WBC-7.3 RBC-2.38* Hgb-7.1* Hct-22.9*
MCV-96 MCH-29.9 MCHC-31.1 RDW-21.7* Plt Ct-105*
[**2177-2-5**] 10:03PM BLOOD WBC-7.9 RBC-2.61* Hgb-8.0* Hct-24.5*
MCV-94 MCH-30.6 MCHC-32.7 RDW-21.6* Plt Ct-79*
[**2177-2-5**] 01:54PM BLOOD Hct-27.4*
[**2177-2-5**] 05:26AM BLOOD WBC-9.0 RBC-2.67* Hgb-8.2* Hct-24.8*
MCV-93 MCH-30.5 MCHC-32.9 RDW-21.7* Plt Ct-85*
[**2177-2-4**] 03:36PM BLOOD WBC-10.6# RBC-2.99* Hgb-9.0* Hct-28.3*
MCV-95 MCH-30.0 MCHC-31.7 RDW-21.3* Plt Ct-105*
[**2177-2-15**] 12:51AM BLOOD Neuts-81.1* Lymphs-17.4* Monos-1.4* Eos-0
Baso-0.1
[**2177-2-14**] 02:01AM BLOOD Neuts-81.7* Lymphs-15.2* Monos-2.8
Eos-0.1 Baso-0.2
[**2177-2-8**] 12:41PM BLOOD Neuts-70.2* Lymphs-24.3 Monos-3.9 Eos-1.2
Baso-0.3
[**2177-2-15**] 12:51AM BLOOD Anisocy-1+ Poiklo-1+ Microcy-1+
[**2177-2-14**] 05:29PM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-1+
Ovalocy-OCCASIONAL Target-OCCASIONAL
[**2177-2-14**] 02:01AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+
[**2177-2-8**] 12:41PM BLOOD Anisocy-2+ Poiklo-1+ Macrocy-1+
Microcy-1+
[**2177-2-20**] 04:33AM BLOOD Plt Ct-143*
[**2177-2-20**] 04:33AM BLOOD PT-12.3 PTT-27.0 INR(PT)-1.1
[**2177-2-19**] 09:57AM BLOOD Plt Ct-104*
[**2177-2-18**] 07:28PM BLOOD Plt Ct-72*
[**2177-2-18**] 11:28AM BLOOD Plt Ct-74*
[**2177-2-18**] 05:15AM BLOOD Plt Ct-64*
[**2177-2-18**] 05:15AM BLOOD PT-12.0 PTT-26.5 INR(PT)-1.0
[**2177-2-17**] 03:15AM BLOOD Plt Ct-63*
[**2177-2-17**] 03:15AM BLOOD PT-12.5 PTT-25.2 INR(PT)-1.1
[**2177-2-16**] 11:42AM BLOOD PT-13.1 PTT-25.8 INR(PT)-1.1
[**2177-2-16**] 03:04AM BLOOD Plt Ct-50*
[**2177-2-15**] 04:14AM BLOOD Plt Ct-60*
[**2177-2-15**] 04:14AM BLOOD PT-11.5 PTT-24.9 INR(PT)-1.0
[**2177-2-14**] 08:45PM BLOOD Plt Ct-64*
[**2177-2-14**] 08:45PM BLOOD PT-9.3* PTT-24.5 INR(PT)-0.8*
[**2177-2-14**] 05:29PM BLOOD Plt Ct-74*
[**2177-2-14**] 05:29PM BLOOD PT-15.1* PTT-26.6 INR(PT)-1.4*
[**2177-2-14**] 02:35PM BLOOD Plt Ct-94*
[**2177-2-14**] 02:35PM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3*
[**2177-2-14**] 08:53AM BLOOD PT-15.0* PTT-26.8 INR(PT)-1.3*
[**2177-2-14**] 05:38AM BLOOD Plt Ct-113*
[**2177-2-14**] 05:38AM BLOOD PT-15.2* PTT-26.6 INR(PT)-1.4*
[**2177-2-14**] 02:01AM BLOOD Plt Ct-109*
[**2177-2-14**] 02:01AM BLOOD PT-15.7* PTT-26.3 INR(PT)-1.4*
[**2177-2-13**] 05:27PM BLOOD Plt Ct-95*
[**2177-2-13**] 03:25PM BLOOD PT-14.1* PTT-25.1 INR(PT)-1.2*
[**2177-2-13**] 02:12PM BLOOD Plt Ct-84*
[**2177-2-13**] 05:44AM BLOOD Plt Ct-85*
[**2177-2-13**] 05:44AM BLOOD PT-14.2* PTT-27.0 INR(PT)-1.3*
[**2177-2-12**] 05:08PM BLOOD Plt Ct-76*
[**2177-2-12**] 04:38AM BLOOD Plt Smr-LOW Plt Ct-90*
[**2177-2-12**] 04:38AM BLOOD PT-13.1 PTT-23.8 INR(PT)-1.1
[**2177-2-12**] 01:27AM BLOOD Plt Ct-100*
[**2177-2-12**] 01:27AM BLOOD PT-13.8* PTT-25.3 INR(PT)-1.2*
[**2177-2-11**] 08:42PM BLOOD Plt Ct-75*
[**2177-2-11**] 03:46PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2177-2-11**] 03:46PM BLOOD PT-13.0 PTT-24.2 INR(PT)-1.1
[**2177-2-11**] 04:05AM BLOOD PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2177-2-10**] 08:08PM BLOOD Plt Ct-68*
[**2177-2-10**] 08:08PM BLOOD PT-13.4* PTT-25.6 INR(PT)-1.2*
[**2177-2-10**] 01:26PM BLOOD Plt Ct-75*
[**2177-2-10**] 01:26PM BLOOD PT-13.5* PTT-24.0 INR(PT)-1.2*
[**2177-2-10**] 03:10AM BLOOD PT-14.4* PTT-25.4 INR(PT)-1.3*
[**2177-2-9**] 07:45PM BLOOD Plt Ct-73*
[**2177-2-9**] 07:45PM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2*
[**2177-2-9**] 01:41PM BLOOD Plt Ct-71*
[**2177-2-9**] 09:32AM BLOOD Plt Ct-73*
[**2177-2-9**] 05:48AM BLOOD Plt Ct-82*
[**2177-2-9**] 05:48AM BLOOD PT-13.3* PTT-24.3 INR(PT)-1.2*
[**2177-2-9**] 05:48AM BLOOD PT-13.3* PTT-24.3 INR(PT)-1.2*
[**2177-2-9**] 12:55AM BLOOD Plt Ct-78*
[**2177-2-9**] 12:55AM BLOOD PT-13.1 PTT-24.1 INR(PT)-1.1
[**2177-2-8**] 08:40PM BLOOD Plt Ct-76*
[**2177-2-8**] 08:40PM BLOOD Plt Ct-76*
[**2177-2-8**] 04:52PM BLOOD PT-11.9 PTT-22.7 INR(PT)-1.0
[**2177-2-8**] 12:41PM BLOOD Plt Ct-80*
[**2177-2-8**] 12:41PM BLOOD PT-12.3 PTT-25.5 INR(PT)-1.1
[**2177-2-8**] 08:49AM BLOOD Plt Ct-95*
[**2177-2-8**] 08:49AM BLOOD PT-12.6 PTT-23.4 INR(PT)-1.1
[**2177-2-8**] 03:18AM BLOOD Plt Ct-84*
[**2177-2-7**] 11:55PM BLOOD PT-12.9 PTT-25.0 INR(PT)-1.1
[**2177-2-7**] 08:28PM BLOOD Plt Ct-76*
[**2177-2-20**] 04:33AM BLOOD Fibrino-376
[**2177-2-16**] 11:42AM BLOOD Fibrino-389
[**2177-2-15**] 12:51AM BLOOD Fibrino-385
[**2177-2-14**] 05:29PM BLOOD Fibrino-287
[**2177-2-13**] 03:25PM BLOOD Fibrino-436*
[**2177-2-12**] 09:05PM BLOOD Fibrino-323
[**2177-2-12**] 04:38AM BLOOD Fibrino-335
[**2177-2-11**] 08:42PM BLOOD Fibrino-304
[**2177-2-11**] 04:05AM BLOOD Fibrino-289
[**2177-2-10**] 03:10AM BLOOD Fibrino-287
[**2177-2-9**] 12:55AM BLOOD Fibrino-404*
[**2177-2-8**] 08:49AM BLOOD Fibrino-341 D-Dimer-7832*
[**2177-2-8**] 03:18AM BLOOD Fibrino-276 D-Dimer-7656*
[**2177-2-7**] 11:55PM BLOOD Fibrino-285 D-Dimer-8650*
[**2177-2-20**] 04:33AM BLOOD Glucose-103 UreaN-63* Creat-8.8* Na-137
K-4.3 Cl-100 HCO3-24 AnGap-17
[**2177-2-18**] 05:15AM BLOOD Glucose-118* UreaN-89* Creat-8.9*# Na-138
K-4.7 Cl-99 HCO3-23 AnGap-21*
[**2177-2-16**] 03:04AM BLOOD Glucose-131* UreaN-38* Creat-5.0*# Na-143
K-4.0 Cl-103 HCO3-27 AnGap-17
[**2177-2-14**] 05:29PM BLOOD Glucose-125* UreaN-51* Creat-6.7* Na-139
K-5.1 Cl-102 HCO3-25 AnGap-17
[**2177-2-14**] 02:01AM BLOOD Glucose-108* UreaN-44* Creat-6.2*# Na-141
K-4.7 Cl-98 HCO3-29 AnGap-19
[**2177-2-12**] 04:38AM BLOOD Glucose-79 UreaN-52* Creat-6.1*# Na-141
K-3.5 Cl-99 HCO3-31 AnGap-15
[**2177-2-9**] 05:48AM BLOOD Glucose-90 UreaN-31* Creat-5.3* Na-138
K-4.3 Cl-95* HCO3-30 AnGap-17
[**2177-2-8**] 03:18AM BLOOD Glucose-108* UreaN-33* Creat-6.8*# Na-141
K-4.4 Cl-97 HCO3-31 AnGap-17
[**2177-2-7**] 01:03AM BLOOD Glucose-101 UreaN-24* Creat-5.0*# Na-142
K-2.8* Cl-100 HCO3-33* AnGap-12
[**2177-2-5**] 10:03PM BLOOD Glucose-101 UreaN-25* Creat-6.6*# Na-146*
K-3.6 Cl-102 HCO3-29 AnGap-19
[**2177-2-5**] 05:26AM BLOOD Glucose-100 UreaN-53* Creat-12.1* Na-135
K-6.9* Cl-97 HCO3-28 AnGap-17
[**2177-2-14**] 05:29PM BLOOD LD(LDH)-269*
[**2177-2-14**] 02:01AM BLOOD ALT-38 AST-22 LD(LDH)-311* AlkPhos-149*
Amylase-65 TotBili-0.9 DirBili-0.4* IndBili-0.5
[**2177-2-13**] 05:44AM BLOOD ALT-43* AST-30 LD(LDH)-282* AlkPhos-141*
Amylase-67 TotBili-0.6 DirBili-0.4* IndBili-0.2
[**2177-2-7**] 10:25AM BLOOD LD(LDH)-70*
[**2177-2-20**] 04:33AM BLOOD Calcium-8.8 Phos-5.1* Mg-2.3
[**2177-2-18**] 05:15AM BLOOD Albumin-2.9* Calcium-6.6* Phos-6.5*
Mg-2.4
[**2177-2-16**] 03:04AM BLOOD Calcium-8.0* Phos-7.0* Mg-1.9
[**2177-2-14**] 05:29PM BLOOD Calcium-7.9* Phos-6.6* Mg-1.8
[**2177-2-14**] 02:01AM BLOOD Albumin-3.6 Calcium-9.7 Phos-6.0* Mg-1.9
[**2177-2-12**] 04:38AM BLOOD Calcium-8.9 Phos-3.9# Mg-2.0
[**2177-2-10**] 03:10AM BLOOD Calcium-8.2* Phos-7.6* Mg-2.2
[**2177-2-7**] 06:02AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9
[**2177-2-6**] 09:50AM BLOOD Calcium-8.0* Phos-5.5* Mg-2.1
[**2177-2-5**] 05:26AM BLOOD Calcium-8.9 Phos-7.4*# Mg-2.8*
[**2177-2-17**] 06:00AM BLOOD Vanco-25.7*
[**2177-2-15**] 06:10PM BLOOD Vanco-21.9*
[**2177-2-8**] 05:16AM BLOOD Vanco-81.8*
[**2177-2-19**] 04:53PM BLOOD Type-MIX pH-7.35
[**2177-2-15**] 01:27AM BLOOD Type-ART pO2-153* pCO2-29* pH-7.55*
calTCO2-26 Base XS-4
[**2177-2-14**] 05:45PM BLOOD Type-ART Temp-37.2 pO2-141* pCO2-43
pH-7.46* calTCO2-32* Base XS-6
[**2177-2-14**] 12:25PM BLOOD Type-ART pO2-174* pCO2-49* pH-7.41
calTCO2-32* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED
[**2177-2-7**] 10:53AM BLOOD Type-[**Last Name (un) **] pH-7.48*
[**2177-2-4**] 01:09PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-45 pH-7.44
calTCO2-32* Base XS-5
[**2177-2-15**] 04:42AM BLOOD Glucose-126* Lactate-0.8 K-5.2
[**2177-2-14**] 08:54PM BLOOD Glucose-114* Lactate-1.7 K-5.1
[**2177-2-14**] 03:00PM BLOOD Lactate-1.7
[**2177-2-13**] 03:43PM BLOOD Lactate-1.2
[**2177-2-4**] 01:09PM BLOOD Glucose-131* Lactate-2.4* Na-138 K-5.4*
Cl-99*
[**2177-2-4**] 09:16AM BLOOD Glucose-100 Lactate-2.0 Na-140 K-4.9
Cl-97*
[**2177-2-15**] 04:42AM BLOOD O2 Sat-98
[**2177-2-14**] 12:25PM BLOOD Hgb-9.1* calcHCT-27
[**2177-2-4**] 11:10AM BLOOD Hgb-10.3* calcHCT-31
[**2177-2-19**] 04:53PM BLOOD freeCa-1.15
[**2177-2-15**] 01:27AM BLOOD freeCa-1.15
[**2177-2-14**] 05:45PM BLOOD freeCa-0.98*
[**2177-2-14**] 12:25PM BLOOD freeCa-1.01*
[**2177-2-7**] 10:53AM BLOOD freeCa-1.03*
[**2177-2-4**] 01:09PM BLOOD freeCa-1.04*
[**2177-2-4**] 09:16AM BLOOD freeCa-1.09*
***RECENT RESULTS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2177-3-4**] 07:30AM 8.1 3.56* 10.6* 33.2* 93 29.9 32.0 18.2*
134*
[**2177-3-1**] 12:20PM 9.8 3.48* 10.3* 32.1* 93 29.7 32.1 18.2*
146*
[**2177-2-28**] 05:45AM 6.9 3.19* 9.7* 29.2* 92 30.3 33.0 18.3*
157
[**2177-2-27**] 07:40AM 8.2 3.16* 9.6* 28.3* 90 30.5 34.0 18.1*
180
BASIC COAGULATION PT PTT INR(PT) Plt
[**2177-2-27**] 07:40AM 12.5 28.3 1.1 180
[**2177-2-25**] 06:50AM 11.6 27.4 1.0 210
[**2177-2-24**] 05:20PM 11.8 27.7 1.0
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2177-3-4**] 07:30AM 113* 32* 9.4* 139 4.9 99 25 20
[**2177-3-1**] 12:20PM 27* 8.7* 138 5.3* 97
[**2177-2-27**] 07:40AM 75 34* 8.9*# 136 5.0 99 25 17
PTH
[**2177-3-5**] 05:40AM 361*
HEPATITIS HBsAg HBsAb
[**2177-3-5**] 05:40AM PND PND
Brief Hospital Course:
- The patient was admitted on [**2-4**] and underwent left
laparoscopic radical nephrectomy and right laparoscopic radical
nephrectomy the same day. EBL 100cc. There were no
intraoperative complications. The patient was stable and was
transferred to the floor. The patient's post-operative course
was complicated by post-op bleeding noted as increased abdominal
pain and falling hematocrit on POD 2. The patient was
transferred to the intensive care unit and Hematology was
consulted. She was started on vancomycin for elevated temps.
The patient was found to have a coagulopathy and aggressive
resuscitation was started. She was also found to have a
decreasing Plt count, thought to be from her uremia. She was
transfused with PRBC's, platelets, FFP and cryo PRN to maintain
her levels. A HIT Ab panel was sent which came back negative on
the final tests. See table below for details.
-PreOp --- Hct 33.4 BP 90/57
[**2-5**] (POD#1) Stable on 12R, sips --- Hct 27.4
BP 90/52
[**2-6**] (#2) taking clears, [**Last Name (un) 103**] pain in pm --- Hct 25.9 BP
85/55
[**2-7**] (am) low bp ?????? transfer unit --- Hct 20.2 BP
85/50
Initial Hematology consult ?????? possible DIC. Given baseline uremia
manage with DDAVP, FFP, Cryo for fibrinogen > 100 and platelets
for > 100.
Initial Coagulation and DIC screen
PT 13.8, PTT 66, INR 1.2
Fibrinogen 405, FDP 10-40, D-dimer 8500, Thrombin 150
-On POD #3 a CT of abd/pelvis was obtained which revealed 1.
Bilateral retroperitoneal hematomas with some active
extravasation on the left and the patient is status post
bilateral nephrectomy. 2. Free intraperitoneal air status
postop. 3. Coronary artery calcifications. 4. Several cystic
areas in the pancreas which measure 1-2 mm which may represent
IPMT. She contineud to have a significant requirement for PRBC's
(9 units total at this point), platelets, and cryo. She was
continued on DDAVP and was continued on hemodialysis. Due to
difficulties in peripheral access a right femoral line was
placed. An ECHO was obtained on POD #5 which revelaed a Linear
mitral annular echodensity and mitral regure, which was seen on
a previos echo. Blood and sputum cultures were sent which were
both negative. The renal team followed the patient regarding her
dialysis and electrolyte control. On POD #[**5-15**] the patient's
platelt counts and coags stabilized and the DDAVP was held. She
was kept on Vitamin K and estrogens.
-On POD #9 the patient had a large requirement in her pain
medications and developed severe increasing abdominal pain. She
also had increased bleeding around her incision. A CT scan was
obtained which showed 1. Marked interval increase in size of
right retroperitoneal hematoma in the nephrectomy bed. Given
the relative high attenuation of this collection, the degree of
short-term increase in size, and the presence of a small
hyperenhancing focus, active extravasation cannot be excluded.
2. Relatively stable left retroperitoneal hematoma. 3. Stable
bilateral lower lobe airspace disease. . Stable cardiomegaly.
Due to this finding the transplant general surgery team was
consulted and it was felt that would need to return to the OR
for a washout and to stop the bleeding. Her HCT reached a nadir
of 18.0 for which she was transfused 5 units.
-The patient was transferred to the SICU on the [**Hospital Ward Name **] and
taken to the OR on POD #10 with Dr. [**Last Name (STitle) 3748**] and Dr. [**Last Name (STitle) **]. In
the OR The right colon was mobilized and the large clot
evacuated from the right retroperitoneum. Hemostasis was secured
with argonbeam coagulation, application of topical hemostatic
sheets and fibrin glue. There was a small hematoma on the left
retroperitoneum, which was also controlled in a similar fashion.
There were several mesenteric hematomas both in the small and
large bowel, but all of the colon and small bowel itself was
viable. Please see Dr. [**Last Name (STitle) 18846**] operative note for further
details. The patient tolerated the procedure well and was sent
back to the SICU postoperatively. She was given activated factor
VIIa in the post operative period, which greatly improved her
coagulopathies. At this point in her stay she had required 17u
PRBC, 11u platelets, and 4u of cryo. After being given the
factor VII, the patient did not require any further transfusions
of blood products for the remainder of her hospital stay.
-She was found to be hemodynamically stable and remained so,
therefore she was transferred to the floor. Post-operatively she
did very well. Her HCT's remained stable and her adbominal exam
was much improved. Her vanco was d/c'd and her JP drains were
d/c'd on [**2-18**]. She was continued on dialysis and her pain was
controlled with a PCA. A chronic pain service consult was
requested who started her on a PO pain regimen on [**2177-2-19**]. Her
pain was controlled with PO meds, she was tolerating a regular
renal diet, and her CVL was d/c's on [**2177-2-20**]. The renal team
continued to follow to assist with her electrolye imbalances and
dialysis management. Over the weekend on [**4-23**] the patient
did extremely well - she was able to ambulate, her pain was
controlled on PO meds, and she was tolerating a regular diet. On
[**2-24**] the patient developed increasing left abdominal pain and
her HCT dropped 4 points. The next day her HCt was down another
two points and a noncontrasted CT scan was obtained which
revealed 1. Post-surgical changes in both nephrectomy beds with
fibrin net placement. 2. Decreased size of right nephrectomy
bed hematoma. 3. Slight increase in size of fluid collection in
left nephrectomy site. High-density internal areas likely
represent residual clot. The collection is lower in Hounsfield
units than on the prior study and is likely due to combination
of hematoma and fluid. The patient was felt to be stable and a
post dialysis HCT on [**2-26**] was back up to 31 (stable from
previous checks). Blood cultures were sent on [**2-27**] and her HCT
was stable. The patient continued to do well, tolerating her
renal diet, ambulating, and her pain controlled on PO
medications.
-Due to some increase in abdominal pain on [**3-1**], a CT repeat CT
was obtained which revelaed postsurgical changes in both
nephrectomy beds with bilateral hematomas in evolution, which
have not significantly changed in size compared to 4 days prior
but are smaller and liquifying compared to [**2-13**]. On [**3-2**] a
CXR was taken to evaluate some consolidation seen on the upper
cuts of her abd CT. The CXR showed: Slight improvement in fluid
balance with persistent bilateral patchy opacities in lung
bases, suspicious for pneumonia or aspiration. Underlying
pulmonary arterial hypertension as previously noted. The
pulmonoly team was asked for advice on treatment of the
consolidation and PA HTN, and recommended no Abx at this time
due to the fact the the patient has no clinical symptoms of a
pneumonia, she has been afebrile, and has a normal WBC. She will
followup in pulmonology clinic for further eval of her PA HTN.
On [**2096-3-1**] she was much improved. Her labs were stable and she
had no further complaints. All of her cultures were negative to
date, she has been afebrile, and has a normal WBC count. She is
being discharged in stable condition, tolerating a regular renal
diet, pain control on PO meds, ambulating well, with stable
HCT's, WBC's, and a benign abdominal exam. She will start back
on her home dialysis schedule at [**Hospital 1263**] hospital and will f/u
with her PCP, [**Name10 (NameIs) **], and Dr. [**Last Name (STitle) 3748**].
Medications on Admission:
AMOXIL 500 mg--4 tablet(s) by mouth 4 tabs one hour prior to
procedure then 1 tab every 8 hours 1 hour prior to procedure
AZTREONAM 1 gram--1 gram iv q24 hours until [**11-26**]
Amitriptyline 50 mg--1 tablet(s) by mouth at bedtime for
neuropathy
DILAUDID 4 mg--1 tablet(s) by mouth twice a day as needed for
pain
IBUPROFEN 600MG--One pill by mouth every 6-8 hours as needed for
joint pain
NEPHROCAPS 1MG--One by mouth every day
PREDNISONE 5MG--Take as directed
PROTONIX 20MG--One by mouth every day for gerd
Sevelamer 800 mg--1 tablet(s) by mouth three times a day
phosphate binder
Amitriptyline 75 mg--1 tablet(s) by mouth at bedtime for
neuropathy
Discharge Medications:
1. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. B-Complex with Vitamin C Tablet [**Month/Year (2) **]: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sevelamer 800 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
8. Amitriptyline 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
Q72H (every 72 hours).
Disp:*10 patches* Refills:*2*
10. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
11. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
care group vna
Discharge Diagnosis:
Bilateral renal masses
Discharge Condition:
Stable
Discharge Instructions:
[**Name8 (MD) **] M.D. if fever > 101.5, nausea, vomiting, increasing
abdominal pain, shortness of breath, chest pain, difficulty
urinating, , noted bleeding, dizziness, or any other concerns.
[**Month (only) 116**] resume a regular renal diet as directed. Activity as
tolerated except no heavy lifting or strenuous activity. You may
take a shower but no tub bathing or soaking until followup. A
VNA will visit you for the first week to assess your wound and
make sure you are not having any problems.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 3748**] in 2 weeks. Please call ([**Telephone/Fax (1) 18591**] to schedule your appointment.
Please call for an appointment to followup with Pulmonology.
Call ([**Telephone/Fax (1) 513**] to schedule an appointment in [**12-10**] weeks for
followup of pulmonary hypertension.
Please followup with you PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1 week for reassesment
of your home medications, followup. Call ([**Telephone/Fax (1) 18847**].
Please resume your normal dialysis schedule at [**Hospital 1263**] hospital.
Please call [**Telephone/Fax (1) 18848**] to set up your next
appointment
Completed by:[**2177-3-5**]
ICD9 Codes: 5856, 2851, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4487
} | Medical Text: Admission Date: [**2127-1-8**] Discharge Date: [**2127-1-14**]
Date of Birth: [**2102-9-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
tylenol and paxil overdose
Major Surgical or Invasive Procedure:
Right IJ Placement
History of Present Illness:
HPI: 24 previously healthy female presents as direct admission
to Transplant Surgery ICU for tylenol overdose. Patient reports
having a recent break-up with her fiance and between yesterday
afternoon to this morning ingested ~ 80-100 tablets of tylenol
PM
along with ten tabs (30 mg) of Paxil. After telling her mother
what she had done, she was [**Last Name (un) 4662**] to the [**Hospital 792**]Hospital
ED
this morning (~ 9AM). She reports no abdominal pain, but has
mid-chest pain and throat pain/burnig. She reports feeling
unsteady and slightly forgetful. She also reports vomiting some
pill fragments. Per records, at OSH Ed she was bolused with
loading dose of NAC (8200 mg IV, 150 mg/kg) and recieved 1 L of
NS. She was transferred to [**Hospital1 18**] for further treatment. She
denies recent EtOH use. She reports smoking marijuana ~ 2 days
ago after work but denies any other drug use. She reports
having
sweats but denies fevers, chills, diarrhea or constipation.
Past Medical History:
PMH: panic attacks/anxiety
PSH: c-section
Social History:
Lived with her fiance and their 3 year old daughter. She is
employed as a cook. Her family lives nearby. Her fiance's
family lives in [**Male First Name (un) 1056**]. She denies suicide attempts or
ever
attempting overdose in the past. She reports rare EtOH use.
Occasional marijuana. [**1-20**] PPD smoker x ~4 years.
Family History:
Non contributory
Physical Exam:
On Admission:
VS: 97.8 110 152/85 20 96% RA
Gen: NAD, AOx3 with occasional innappropriate responses and
attention loss, but easily re-oriented
CVS: sinus tachycardia
Pulm: CTA-B, no respiratory distress
Abd: S/NT/ND no rebound, no guarding
Ext: no LLE, no track marks on arms
.
GENERAL: Well appearing 24yo M/F who appears stated age.
Comfortable, appropriate.
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: S1 S2 clear. No MRG noted. Difficult to appreciate for
S3 or S4 given tachycardia.
LUNGS: Nonlabored with no accessory muscle use, moving air well
and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Thin, with small amount of redundant skin. NABS. Soft,
nontender and nodistended. No HSM noted.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
NEURO: AAOx3. CNII-XII grossly intact. Strength 5/5 throughout.
No gross sensory loss. Cerebellar fxn intact to FTN.
Pertinent Results:
Labs on Admission:
[**2127-1-8**] 08:19PM BLOOD WBC-9.4 RBC-4.09* Hgb-13.0 Hct-36.3
MCV-89 MCH-31.8 MCHC-35.8* RDW-13.0 Plt Ct-175
[**2127-1-8**] 08:19PM BLOOD PT-35.3* PTT-33.0 INR(PT)-3.4*
[**2127-1-8**] 08:19PM BLOOD Glucose-59* UreaN-9 Creat-0.5 Na-142
K-2.8* Cl-111* HCO3-20* AnGap-14
[**2127-1-8**] 08:19PM BLOOD ALT-1139* AST-918* LD(LDH)-666*
AlkPhos-84 Amylase-38 TotBili-6.1*
.
Labs on Discharge:
[**2127-1-13**] 06:20AM BLOOD WBC-6.1 RBC-4.16* Hgb-13.1 Hct-36.6
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 Plt Ct-191
[**2127-1-13**] 06:20AM BLOOD PT-13.1* PTT-42.1* INR(PT)-1.2*
[**2127-1-13**] 06:20AM BLOOD Glucose-89 UreaN-17 Creat-0.6 Na-139
K-4.3 Cl-105 HCO3-29 AnGap-9
[**2127-1-14**] 01:05PM BLOOD ALT-1582* AST-86* AlkPhos-96 TotBili-1.2
[**2127-1-13**] 06:20AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.0
.
[**2127-1-8**] 08:19PM BLOOD calTIBC-270 Ferritn-558* TRF-208
[**2127-1-13**] 06:20AM BLOOD TSH-<0.02*
[**2127-1-13**] 06:20AM BLOOD T4-11.8 T3-126
[**2127-1-8**] 08:19PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD HCG-<5
[**2127-1-8**] 08:19PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD CEA-<1.0 AFP-1.2
[**2127-1-8**] 08:19PM BLOOD IgG-1049 IgA-179 IgM-80
[**2127-1-8**] 08:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-119*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-1-11**] 06:02AM BLOOD Lactate-0.9
.
[**2127-1-8**] Right Upper Quadrant:
IMPRESSION:
1. Normal liver echotexture without discrete lesions.
2. Gallbladder wall edema, most likely related to acute
hepatitis.
3. An incompletely imaged left renal cystic lesion with internal
focus of
increased echogenicity, may represent calcification within a
calyceal
diverticulum. Follow up dedicated renal ultrasound exam when the
patient's
condition stabilizes is recommended for further evaluation.
.
[**2127-1-8**] CXR: FINDINGS: Normal size of the cardiac silhouette.
Normal hilar and mediastinal contours. No pleural effusions. No
pneumothorax, no pneumonia, no pulmonary edema. Unremarkable
morphology in the upper abdomen
.
[**2127-1-9**] Echo: Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) 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.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 24 year old female with history of
depression/anxiety who presented with acute liver failure after
suicide attempt by tylenol/paxil ingestion.
.
#. Acute Liver Failure: Patient was initially cared for in the
surgical intensive care unit given concern that liver failure
would progress and she would need transplant. Transplant
evaulation was initiated with psych, social work and hepatology
consultation. N-Acetylcysteine was continued per fulminant liver
failure pathway. Initially INR climbed and peaked at 6.2 prior
to trending down. Bilirubin trended up to 6.1 prior to returning
to normal range. The patient developed no renal dysfunction.
Patient did develop mild encephelopathy which promptly resolved
with improvement in her liver function. Her liver function
continued to improve during hospitalization.
.
#. Depression/Anxiety: Now with suicide attempt. Psychiatry was
consulted and recommended section 12 and 1:1 sitter. Patient was
followed by psychiatry and transfered to an inpatient facility.
Per psychiatry recommendations patient's paxil was held.
.
#. Tachycardia: EKG revealed sinus tachycardia. TSH was checked
and <0.02. T3 and T4 were within normal range. Endocrinology was
consulted and recommended T3 uptake scan which will be completed
during the psychiatric admission. Endocrinology will continue to
follow the patient. Propanolol was started with improvement in
the patient's heart rate.
.
#. Urinary Tract Infection: Complicated in setting of foley
catheter placement. Patient to complete 7 day course of
Ciprofloxacin for treatment.
.
FOLLOW UP/TRANSITIONAL ISSUES:
1. Ciprofloxacin should be continued for 4 more days to complete
7 day course for complicated UTI
2. Patient should have Thyroid uptake scan on [**2128-1-15**].
Endocrinology is follow patient and will make further
recommendations.
3. Appreciate endocrinology recommendations.
Medications on Admission:
paxil 30 mg daily
Discharge Medications:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
3. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Depression/Anxiety
Hyperthyroidism
Tachycardia
Liver Failure secondary to tylenol toxicity
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 caring for you while you were admitted to
[**Hospital1 18**]. During your admission you were monitored very closely in
the intensive care unit given concern for liver failure
secondary to tylenol overdose. With N-Acetylcysteine (a
medication which protects the liver against tylenol) your liver
function improved.
During your stay you were also found to have a fast heart rate
and your thyroid hormone was found to be elevated meaning you
may have hyperthyroidism.
.
You were evaluated by the psychiatric team during your stay and
they recommended inpatient psychiatric evaluation given your
suicide attempt.
The following changes were made to your medications:
-- STOP Paxil
-- START Ciprofloxacin 500mg Twice Daily for 4 more days (for
UTI)
-- START Propanolol 10mg TID for fast heart rate
-- START Nicotine Patch
Please follow up with your primary care physician after
discharge from the psychiatric unit.
Followup Instructions:
After discharge from the psychiatric facility you should follow
up with your primary care physician.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
ICD9 Codes: 5990, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4488
} | Medical Text: Admission Date: [**2105-9-11**] Discharge Date: [**2105-9-18**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 86744**] is an 87-year-old man with a history of hypertension,
atrial fibrillation previously on coumadin, and dementia who was
recently admitted for symptomatic cholelithiasis versus
cholecystitis, underwent ERCP with sphincterotomy, was
discharged to rehab, and is admitted to the [**Hospital Unit Name 153**] after
presenting to an outside hospital with a GI bleed.
.
He was in his usual state of health until [**2105-9-6**] when he was
admitted for symptomatic cholelithiasis versus acute
cholecystitis and underwent ERCP with sphincterotomy. His
procedure was uncomplicated and he was discharged to rehab on
[**2105-9-10**]. He was previously on aspirin and coumadin and these
medications were held on discharge, with a plan to restart on
[**2105-9-12**]. He was doing well until the following day when he had
an episode of sharp, periumbilical abdominal pain that lasted
several hours and resolved after an episode of dark brown
emesis. He presented to an OSH for further evaluation. There,
his hct at presentation was 26 from a baseline in the low 30s,
and he had an episode of coffee ground emesis and he was
transferred to [**Hospital1 18**] for further evaluation. En route, he had
an episode of melanotic diarrhea.
.
In the [**Hospital1 18**] ED, initial vs were: 98.3 62 183/84 16 97%2L. His
exam was notable for a nontender abdomen and melanotic liquid
stools per rectum. He denied chest pain, light-headedness, or
dyspnea. Pantoprazole bolus followed by gtt was initiated and
ED staff consulted ERCP. They recommended supportive care with
possible endoscopy in the a.m. Peripheral IVs (16G and 18G)
were placed, and he was crossmatched for four units. An NG
lavage was deferred per ERCP and he was transferred to the [**Hospital Unit Name 153**].
Hct was 28 prior to transfer.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Dementia
Atrial fibrillation on warfarin
s/p aortic valve repair [**12/2100**] with bioprosthetic valve t [**Location 87492**] VA
ICD implantation [**8-/2101**]
Hypertension
History of depression
Degenerative joint disease
hyperlipidemia
GERD
benign prostatic hypertrophy
macular degeneration
s/p right knee replacement [**4-/2102**]
Social History:
reports no alcohol or tobacco use. He previously served in the
Air Force. Widowed, lives in [**Hospital3 **]. Daughter and son
are very involved.
Family History:
Unavailable from patient due to dementia.
Physical Exam:
ADMISSION
VS: 98 82 170/84 21 98%2L
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**1-31**] SM
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A/O to person and place, appropriate and conversant. [**4-29**]
UE/LE strength grossly
Pertinent Results:
[**2105-9-18**] 07:25AM BLOOD WBC-9.3 RBC-3.40* Hgb-11.4* Hct-33.3*
MCV-98 MCH-33.6* MCHC-34.3 RDW-16.6* Plt Ct-212
[**2105-9-17**] 07:05AM BLOOD WBC-8.8 RBC-3.25* Hgb-10.7* Hct-32.3*
MCV-99* MCH-32.8* MCHC-33.1 RDW-16.7* Plt Ct-212
[**2105-9-16**] 07:40AM BLOOD WBC-8.9 RBC-3.28* Hgb-10.7* Hct-32.5*
MCV-99* MCH-32.7* MCHC-33.0 RDW-16.8* Plt Ct-204
[**2105-9-15**] 08:00PM BLOOD WBC-10.9 RBC-3.57* Hgb-11.3* Hct-34.8*
MCV-98 MCH-31.6 MCHC-32.4 RDW-16.4* Plt Ct-224
[**2105-9-15**] 07:40AM BLOOD WBC-11.0 RBC-3.60* Hgb-11.8* Hct-35.1*
MCV-98 MCH-32.7* MCHC-33.5 RDW-17.0* Plt Ct-228
[**2105-9-14**] 04:46PM BLOOD Hct-36.4*
[**2105-9-14**] 05:00AM BLOOD WBC-9.3 RBC-3.39* Hgb-10.9* Hct-32.5*
MCV-96 MCH-32.2* MCHC-33.6 RDW-17.2* Plt Ct-195
[**2105-9-13**] 11:00PM BLOOD WBC-10.5 RBC-3.34* Hgb-11.0* Hct-31.8*
MCV-95 MCH-32.9* MCHC-34.6 RDW-17.6* Plt Ct-190
[**2105-9-13**] 04:50PM BLOOD Hct-31.7* Plt Ct-170
[**2105-9-13**] 10:58AM BLOOD Hct-32.5*
[**2105-9-13**] 04:50AM BLOOD WBC-10.9 RBC-3.39*# Hgb-11.0*# Hct-32.0*
MCV-94 MCH-32.4* MCHC-34.4 RDW-18.3* Plt Ct-189
[**2105-9-13**] 01:57AM BLOOD Hct-31.9*#
[**2105-9-12**] 07:48PM BLOOD WBC-10.3 RBC-2.49* Hgb-8.2* Hct-24.4*
MCV-98 MCH-32.8* MCHC-33.5 RDW-16.8* Plt Ct-168
[**2105-9-12**] 11:06AM BLOOD Hct-26.6*
[**2105-9-12**] 05:03AM BLOOD WBC-14.4* RBC-2.86* Hgb-9.5* Hct-28.0*
MCV-98 MCH-33.3* MCHC-34.0 RDW-17.6* Plt Ct-237
[**2105-9-17**] 07:05AM BLOOD PT-16.0* INR(PT)-1.4*
[**2105-9-10**] 06:00AM BLOOD PT-17.2* INR(PT)-1.5*
[**2105-9-18**] 07:25AM BLOOD UreaN-17 Creat-1.2 Na-139 K-4.0 Cl-105
HCO3-27 AnGap-11
[**2105-9-17**] 07:05AM BLOOD Glucose-88 UreaN-17 Creat-1.3* Na-139
K-4.2 Cl-106 HCO3-28 AnGap-9
[**2105-9-10**] 06:00AM BLOOD Glucose-106* UreaN-16 Creat-1.3* Na-141
K-3.8 Cl-107 HCO3-26 AnGap-12
[**2105-9-17**] 07:05AM BLOOD ALT-69* AST-48* AlkPhos-88 TotBili-2.0*
[**2105-9-15**] 07:40AM BLOOD ALT-84* AST-64* AlkPhos-104 TotBili-3.0*
[**2105-9-14**] 05:00AM BLOOD ALT-73* AST-59* AlkPhos-98 TotBili-2.9*
[**2105-9-13**] 04:50AM BLOOD ALT-65* AST-45* AlkPhos-96 Amylase-31
TotBili-3.6*
[**2105-9-11**] 10:27PM BLOOD ALT-92* AST-119* CK(CPK)-142 AlkPhos-114
TotBili-3.3*
[**2105-9-10**] 06:00AM BLOOD ALT-111* AST-58* AlkPhos-150*
TotBili-4.9*
[**2105-9-16**] 07:40AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
[**2105-9-11**] 10:28PM BLOOD Glucose-113* Lactate-1.3 Na-142 K-4.5
Cl-108 calHCO3-25
[**2105-9-18**]: Left leg ultrasound. PRELIM!! No DVT
[**2105-9-15**] echo:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is low normal (LVEF
50%) secondary to hypokinesis of the inferior and posterior
walls. Right ventricular chamber size and free wall motion are
normal. [Intrinsic right ventricular systolic function is likely
more depressed given the severity of tricuspid regurgitation.]
The ascending aorta is mildly dilated. A bioprosthetic aortic
valve prosthesis is present. The prosthetic aortic valve
leaflets are thickened. The transaortic gradient is normal for
this prosthesis. A paravalvular aortic valve leak (mild) is
present. The valve appears stable without evidence of
dehiscence. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2105-9-13**] chest x ray:
Cardiac size is top normal. The lungs are hyperinflated. A small
left and
small-to-moderate right pleural effusion have increased
associated with
adjacent opacities consistent with atelectasis. Left pacer lead
terminates in standard position in the right ventricle. There is
no pneumothorax. The
lungs are hyperinflated. Moderate degenerative changes are in
the thoracic
spine. Sternal wires are aligned.
Brief Hospital Course:
GI bleed:
Pt underwent ERCP w sphincterotomy on [**9-7**], had previously been
taken off aspirin and coumadin, now presenting w melena and
coffee ground emesis. HCT stabilized after 4 units of PRBC. He
also rec'd IV vitamin K for an INR of 1.5. He did not undergo
repeat EGD given stability and that the sphincterotomy site was
very likely the culprit. His hct was stable over days and a
plan was made with the patient and his outpatient cardiologist
to cautiously restart aspirin and coumadin. Aspirin should be
restarted if there is no rebleed on [**9-20**] and coumadin 1 week
later on [**9-27**] if there is no rebleed. In the setting of the
bleed he has an elevation of LFTs which was likely related to
blood versus blood clot, these abnormalities improved. There
was an associated WBC of 11 and low grade temps. Ciprofloxacin
added for planned 1 week course, he has 3 remaining days upon
discharge and is symptom free and without fevers, WBC has
returned to [**Location 213**].
HYPERTENSION:
Continued on his beta blocker and norvasc. Given mild ARF his
lisionpril and lasix were held. Lasix restarted at home dose of
20mg daily upon discharge and his lisinopril should be restarted
as an oupt. I suggest rechecking chemistry on [**9-25**] or around
there prior to restarting.
Atrial fibrillation: digoxin and metoprolol continued. Coumadin
held as above.
Medications on Admission:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
10. Prilosec 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. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for fever or pain: Up to 2 g of tylenol per day.
13. Trixaicin 0.025 % Cream Sig: One (1) application Topical
once a day: To eyes and forehead.
14. Coumadin 4 mg Tablet Sig: One (1) Tablet PO daily: start
[**9-12**]
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO daily: start
[**9-12**]
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
plan to start on [**9-25**] if creatinine stable (1.2 or less).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
DAILY (Daily).
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Trixaicin Topical
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Primary Diagnosis:
Gastrointestinal bleed
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a bleed in your small intestine, likely
at the site of your prior procedure. This stopped on its own
and you received blood transfusions. You will need to continue
to hold your aspirin and coumadin as directed. Please return
immediately should you have any further bleeding or black stool.
MEDICATION CHANGES:
stop taking your aspirin, you can restart aspirin 81mg daily on
[**2105-9-20**] if you have no further bleeding
stop taking your coumadin, you can restart coumadin at your
regular dose on [**9-27**] if you have no further bleeding
start taking ciprofloxacin for 3 additional days
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of your discharge from the hospital. [**Last Name (LF) **],[**First Name3 (LF) **]
[**Telephone/Fax (1) 49102**]
ICD9 Codes: 4019, 2724, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4489
} | Medical Text: Admission Date: [**2175-6-8**] Discharge Date: [**2175-6-12**]
Date of Birth: [**2106-8-17**] 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:
CABG X 4 (LIMA>LAD, SVG>OM, SVG>PDA>PLV) [**6-9**]
History of Present Illness:
68 yo M presented to OSH with fever to 104.9, shaking/chills.
Started on rocephin and zithromax for question of sinus
infection. All cultures negative on transfer. Noted to have
chest pain, stress echo positive, cardiac cath showed 3VD,
transferred for surgical evaluation.
Past Medical History:
hyperlipidemia, htn, oa b/l knees, chronic sinusitis, b/l tkr,
b/l hip replacements
Social History:
quit cigars about 10 years ago
rare etoh
Family History:
father deceased from CVA at age 56
o/w unknown
Physical Exam:
HR 78 RR 18 BP 132/88 Temp 98.6
NAD
Lungs CTAB
Heart RRR no N/R/G
Abdomen soft/NT/ND
Extrem earm, no edema
No varicosities
No carotid bruits
Pertinent Results:
[**2175-6-12**] 05:41AM BLOOD WBC-13.2* RBC-3.56* Hgb-10.6* Hct-29.9*
MCV-84 MCH-29.7 MCHC-35.3* RDW-13.8 Plt Ct-320
[**2175-6-9**] 12:28PM BLOOD PT-15.1* PTT-31.1 INR(PT)-1.3*
[**2175-6-12**] 05:41AM BLOOD Glucose-110* UreaN-16 Creat-1.1 Na-137
K-3.5 Cl-97 HCO3-32 AnGap-12
CHEST (PORTABLE AP) [**2175-6-10**] 12:27 PM
CHEST (PORTABLE AP)
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
68 year old man s/p chest tube removal
REASON FOR THIS EXAMINATION:
PTX
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Assess for pneumothorax post chest tube
removal.
Comparison is made to prior study performed a day earlier.
There is no pneumothorax or sizable pleural effusions. There are
low lung volumes. Cardiomediastinal silhouette is stable. There
has been interval improvement of bibasilar atelectasis greater
in the lft side, there is also improvement in fluid overload,
mediastinal wires are aligned.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78732**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78733**] (Complete)
Done [**2175-6-9**] at 8:45:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-8-17**]
Age (years): 68 M Hgt (in): 68
BP (mm Hg): 120/80 Wgt (lb): 180
HR (bpm): 66 BSA (m2): 1.96 m2
Indication: coronary artery disease
ICD-9 Codes: 786.05, 440.0, 424.1
Test Information
Date/Time: [**2175-6-9**] at 08:45 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch. Normal descending
aorta diameter. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic 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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications 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 mildly thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**Known firstname **] [**Known lastname **].
POST_BYPASS:
Preserved biventricular systolic function. LVEF 55%.
Thoracic aortic contour is intact.
Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **] and AI
Brief Hospital Course:
He was admitted to cardiac surgery. Rocephin, zithromax and
tylenol were dc'd. He had no fever. He was taken to the
operating room on [**6-9**] where he underwent a CABG x 4. He was
transferred to the ICU in stable condition. He was extubated
later that same day. He was given 48 hours of vancomycin as he
was an inpatient for > 24 hours prior to surgery. He was
transferred to the floor on POD #1. He did well postoperatively
and was ready for discharge home on POD #3.
Medications on Admission:
asa 81', atenolol/chlorthalidone 50/25', crestor 5', doxycycline
100', aleve prn
Discharge Medications:
1. 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*
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 3
days.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Crestor 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home health
Discharge Diagnosis:
CAD now s/p CABG
hyperlipidemia, htn, oa b/l knees, chronic sinusitis, b/l tkr,
b/l hip replacements
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78734**] [**Telephone/Fax (1) 78735**] 6 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] [**Telephone/Fax (1) 66607**] 4 weeks
Dr. [**Last Name (STitle) 914**] 2 weeks
Completed by:[**2175-6-12**]
ICD9 Codes: 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4490
} | Medical Text: Admission Date: [**2141-4-24**] Discharge Date: [**2141-5-3**]
Date of Birth: [**2083-4-23**] Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
Left forearm swelling
Major Surgical or Invasive Procedure:
s/p multiple incision and drainage, left forearm split thickness
skin graft (donor site - L thigh) with wound vac application:
.
[**2141-4-24**]
1. Decompression fasciotomy, left arm, with epimysiotomy of
all muscle groups.
2. Decompression fasciotomy, left forearm, epimysiotomy of
all muscle groups.
3. Left open carpal tunnel release.
4. Application of vacuum-assisted closure dressing.
.
[**2141-4-26**]
1. Dressing change, debridement left forearm, soft tissue
only.
2. Pulse irrigation and application of vac dressing.
.
[**2141-4-27**]
1. Irrigation and debridement of left arm wound 40 x 15 cm.
2. Placement of vacuum-assisted sponge 14 x 15 cm.
.
[**2141-4-29**]
1. Irrigation and debridement, left arm wound.
2. Partial wound closure, left arm.
3. VAC dressing change.
.
[**2141-5-1**]
1. Debridement left forearm.
2. Split-thickness skin graft left forearm (30 cm x 9.0
cm).
3. Application of VAC dressing.
History of Present Illness:
58M otherwise healthy who developed atruamatic L elbow pain 4
days prior, which he states started on his funny bone. It made
it difficult to move his elbow, and it has gotten progressively
worse. Last night he was seen at an outside hospital where he
had an Xray and labs. He was told he had an "orthopedic problem"
and was referred to a clinic and given pain medication.
Overnight
he developed fever (Tmax 103) and shaking chills, in addition to
N/V. The pain has continued to worsen and now he can barely move
his arm. He is unable to flex or extend his wrist or his elbow
secondary to pain. EMS was called this morning for worsening
symptoms and lightheadedness. In the field he was found to be
hypotensive to the 70s. On arrival to the ED he was
normotensive.
.
He denies recent trauma or similar pain in his elbow. He denies
a known bite or abrasion over his left forearm. He denies any
wounds in the area recently. He denies abdominal pain, chest
pain or shortness of breath. He states he had cold symptoms last
week, which are improving. He has a history of bursitis in this
elbow approximatey 2 years ago, which resolved on it's own.
Past Medical History:
Esophageal ulcer (negative biosy)
.
PSH: s/p transphenoid pituitary tumor removal
Social History:
No Tob/EtOH/IVDU. Works at a desk job
Family History:
N/C
Physical Exam:
PE:
99.2-->103 100 110/62 16 99% RA
General: A&O x 3, Calm, Resting in bed.
EXT: He is uncomfortable with any movement of LUE. Skin over
medial aspect of extensor surface of forewarm erythematous and
edematous. No fluctuance noted. Tenderness over that area to
light touch. Compartment tense. Elbow held at approximately 80
degrees able to extend minimally with severe pain. Pain with
wrist extension and flexion. Grasp weak [**2-15**] pain. Capillary
refill <2 secs in all extremities. No bony tenderness in elbow.
No apparent joint effusion or significant bursa swelling.
Radial,
Median, Ulnar SILT. 2+ radial pulses.
Pertinent Results:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 76008**],[**Known firstname **] [**2083-4-23**] 58 Male [**Numeric Identifier 76009**] [**Numeric Identifier 76010**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Hospital1 **]/dif
.
SPECIMEN SUBMITTED: TENOSYNOVIUM CARPAL CANAL LEFT (1 VIAL),
Forearm Fascia, Tenosynovium Carpal Canal , Forearm muscle.
Procedure date Tissue received Report Date Diagnosed
by
[**2141-4-24**] [**2141-4-25**] [**2141-4-27**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/ttl
Previous biopsies: [**Numeric Identifier 76011**] GI BX (6 jars)
DIAGNOSIS:
I. Tenosynovium, carpal canal (A):
Fibrous tissue with edema and acute inflammation; focal necrosis
and bacterial forms.
II. Left forearm fascia (B-E):
1. Fibroadipose and fascial type tissue with extensive necrosis
and acute inflammation.
2. Tissue Gram's stain reveals numerous Gram's positive cocci.
III. Left forearm muscle (F-G):
1. Fibrous tissue and skeletal muscle with extensive necrosis
and acute inflammation.
2. Tissue Gram's stain reveals numerous Gram's positive cocci.
IV. Tenosynovium carpal canal (H):
Fibroadipose tissue with edema and acute inflammation; focal
necrosis and bacterial forms.
.
[**2141-4-24**]
LEFT ELBOW THREE VIEWS; FOREARM, TWO VIEWS
FINDINGS: No fracture or dislocation identified. No effusions,
subcutaneous
gas or radiopaque foreign body identified. No suspicious blastic
or lytic
lesions.
IMPRESSION: No acute process. No fracture or dislocation.
.
Final Report
CT SCAN OF THE LEFT ARM PERFORMED ON [**2141-4-24**]
Comparison with a radiograph from same day.
IMPRESSION: Diffuse edema in the left forearm, which is notable
in the deep fascial compartments which raises concern for
compartment syndrome. Please correlate clinically. No soft
tissue gas or drainable fluid collection.
.
[**2141-4-24**] 7:30 pm SWAB LEFT FOREARM FASCIA.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2141-4-26**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
[**2141-4-24**] 8:30 pm TISSUE LEFT FOREARM FAT.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 7:30 pm TISSUE LEFT FOREARM FASCIA #2.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 76012**] #[**Numeric Identifier 76013**] @2210,
[**2141-4-24**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 76014**]
([**2141-4-24**]).
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 7:30 pm TISSUE LEFT FOREARM FASCIA #1.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 76014**]
[**2141-4-24**].
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 8:45 pm TISSUE TENOSYNOVIUM CARPAL CANAL - L.
**FINAL REPORT [**2141-4-28**]**
GRAM STAIN (Final [**2141-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
TISSUE (Final [**2141-4-27**]):
BETA STREPTOCOCCUS GROUP A. RARE GROWTH.
SENSI REQUESTED BY DR. [**Last Name (STitle) **],[**Doctor First Name 2482**] [**2141-4-26**].
Sensitivity testing performed by Sensititre.
CLINDAMYCIN. <=0.12MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2141-4-28**]): NO ANAEROBES ISOLATED
.
[**2141-4-27**] 11:41 pm TISSUE LEFT UPPER EXTREMITY.
**FINAL REPORT [**2141-5-2**]**
GRAM STAIN (Final [**2141-4-28**]):
THIS IS A CORRECTED REPORT [**2141-4-30**].
Reported to and read back by DR [**Last Name (NamePattern4) 76015**] [**2141-4-30**] 330PM.
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
PREVIOUSLY REPORTED AS ([**2141-4-28**]).
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name5 (NamePattern1) 76016**] [**Last Name (NamePattern1) 76017**] 0335 ON
[**2141-4-28**].
TISSUE (Final [**2141-5-1**]):
BETA STREPTOCOCCUS GROUP A. HEAVY GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 76018**]
([**2141-4-24**]).
ANAEROBIC CULTURE (Final [**2141-5-2**]): NO ANAEROBES ISOLATED.
.
[**2141-5-1**] 3:36 pm SWAB LEFT FOREARM.
GRAM STAIN (Final [**2141-5-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
ECHO - [**2141-4-27**]:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. 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 estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global left ventricular systolic
function. Borderline normal RV function. No significant valvular
abnormality seen
.
Final Report
PORTABLE CHEST [**2141-4-30**]
CLINICAL INFORMATION: Infection, PICC placement.
FINDINGS:
Frontal view of the chest demonstrates a right-sided PICC
terminating at the cavoatrial junction. There is a patchy
airspace consolidation at the right lung base. There is
atelectasis at the left lung base. There is mild
eventration of the right hemidiaphragm. Remainder of the lungs
is relatively clear. Heart and mediastinum are stable.
[**2141-4-24**] 09:25AM BLOOD WBC-27.5* RBC-4.92 Hgb-15.4 Hct-44.1
MCV-90 MCH-31.3 MCHC-35.0 RDW-12.1 Plt Ct-351
[**2141-4-24**] 02:27PM BLOOD WBC-21.6* RBC-4.21* Hgb-13.3* Hct-38.4*
MCV-91 MCH-31.6 MCHC-34.7 RDW-12.1 Plt Ct-259
[**2141-4-24**] 09:56PM BLOOD WBC-23.7* RBC-4.16* Hgb-13.3* Hct-37.9*
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.4 Plt Ct-302
[**2141-4-25**] 02:21AM BLOOD WBC-21.3* RBC-3.63* Hgb-11.4* Hct-33.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.3 Plt Ct-249
[**2141-4-25**] 05:00PM BLOOD WBC-23.2* RBC-3.91* Hgb-12.4* Hct-35.6*
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.6 Plt Ct-290
[**2141-4-26**] 04:46AM BLOOD WBC-29.0* RBC-3.89* Hgb-12.2* Hct-35.3*
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.4 Plt Ct-307
[**2141-4-27**] 03:24AM BLOOD WBC-29.5* RBC-3.59* Hgb-11.4* Hct-32.2*
MCV-90 MCH-31.7 MCHC-35.4* RDW-12.6 Plt Ct-302
[**2141-4-28**] 01:32AM BLOOD WBC-15.8* RBC-3.72* Hgb-11.5* Hct-33.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.7 Plt Ct-289
[**2141-4-29**] 05:45AM BLOOD WBC-15.3* RBC-3.88* Hgb-12.0* Hct-35.4*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.9 Plt Ct-355
[**2141-4-30**] 05:50AM BLOOD WBC-15.3* RBC-3.65* Hgb-11.4* Hct-33.1*
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt Ct-309
[**2141-5-1**] 05:52AM BLOOD WBC-14.1* RBC-3.69* Hgb-11.6* Hct-33.8*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.5 Plt Ct-329
[**2141-5-2**] 04:30AM BLOOD WBC-12.3* RBC-3.72* Hgb-11.5* Hct-34.3*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-383
[**2141-4-24**] 09:25AM BLOOD Neuts-77* Bands-19* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-25**] 02:21AM BLOOD Neuts-80* Bands-9* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2141-4-25**] 05:00PM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-26**] 04:46AM BLOOD Neuts-89* Bands-5 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-28**] 01:32AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-3
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-1*
[**2141-4-29**] 05:45AM BLOOD Neuts-59 Bands-8* Lymphs-13* Monos-4
Eos-2 Baso-0 Atyps-2* Metas-8* Myelos-4*
[**2141-5-1**] 05:52AM BLOOD Neuts-60 Bands-2 Lymphs-23 Monos-7 Eos-1
Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-1*
[**2141-5-2**] 04:30AM BLOOD Neuts-66 Bands-5 Lymphs-18 Monos-7 Eos-2
Baso-0 Atyps-1* Metas-1* Myelos-0
[**2141-4-24**] 09:25AM BLOOD ESR-51*
[**2141-4-26**] 12:51PM BLOOD ESR-78*
[**2141-4-24**] 09:25AM BLOOD PT-13.5* PTT-20.4* INR(PT)-1.2*
[**2141-4-24**] 09:56PM BLOOD PT-15.7* PTT-31.2 INR(PT)-1.4*
[**2141-4-25**] 02:21AM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2141-4-25**] 10:46PM BLOOD PT-14.3* PTT-30.0 INR(PT)-1.2*
[**2141-4-27**] 03:24AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2141-4-28**] 01:32AM BLOOD PT-13.4 PTT-24.4 INR(PT)-1.1
[**2141-4-24**] 09:25AM BLOOD Glucose-97 UreaN-23* Creat-1.8* Na-137
K-4.4 Cl-96 HCO3-23 AnGap-22*
[**2141-4-24**] 02:27PM BLOOD Glucose-94 UreaN-20 Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-19* AnGap-19
[**2141-4-24**] 09:56PM BLOOD Glucose-100 UreaN-20 Creat-1.2 Na-138
K-4.7 Cl-104 HCO3-20* AnGap-19
[**2141-4-25**] 02:21AM BLOOD Glucose-90 UreaN-17 Creat-1.0 Na-135
K-4.3 Cl-105 HCO3-20* AnGap-14
[**2141-4-25**] 05:00PM BLOOD Glucose-167* UreaN-17 Creat-1.2 Na-133
K-4.3 Cl-94* HCO3-23 AnGap-20
[**2141-4-25**] 10:46PM BLOOD Glucose-111* UreaN-20 Creat-1.1 Na-132*
K-4.4 Cl-100 HCO3-26 AnGap-10
[**2141-4-26**] 04:46AM BLOOD Glucose-134* UreaN-20 Creat-1.1 Na-130*
K-4.4 Cl-98 HCO3-28 AnGap-8
[**2141-4-26**] 12:51PM BLOOD Glucose-89 UreaN-20 Creat-1.0 Na-134
K-4.2 Cl-100 HCO3-25 AnGap-13
[**2141-4-27**] 03:24AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-26 AnGap-12
[**2141-4-28**] 01:32AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-139
K-3.3 Cl-105 HCO3-27 AnGap-10
[**2141-4-30**] 05:50AM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
[**2141-5-1**] 05:52AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-139
K-4.5 Cl-106 HCO3-26 AnGap-12
[**2141-4-24**] 09:25AM BLOOD CK(CPK)-154
[**2141-4-25**] 02:21AM BLOOD ALT-334* AST-204* LD(LDH)-200
AlkPhos-198* TotBili-2.6*
[**2141-4-25**] 05:00PM BLOOD ALT-300* AST-151* LD(LDH)-240
CK(CPK)-562* AlkPhos-203* TotBili-2.7*
[**2141-4-25**] 10:46PM BLOOD CK(CPK)-581*
[**2141-4-27**] 03:24AM BLOOD ALT-173* AST-93* AlkPhos-298*
TotBili-3.1* DirBili-2.4* IndBili-0.7
[**2141-4-28**] 01:32AM BLOOD ALT-152* AST-176* AlkPhos-369*
TotBili-1.8*
[**2141-4-29**] 05:45AM BLOOD ALT-144* AST-153* LD(LDH)-381*
AlkPhos-427* TotBili-1.1
[**2141-5-2**] 04:00PM BLOOD ALT-90* AST-77* LD(LDH)-282* AlkPhos-331*
TotBili-0.6
[**2141-4-27**] 03:24AM BLOOD GGT-138*
[**2141-4-29**] 05:45AM BLOOD Lipase-122*
[**2141-4-24**] 02:27PM BLOOD Calcium-7.1* Phos-3.2 Mg-1.3*
[**2141-4-24**] 09:56PM BLOOD Calcium-7.3* Phos-5.1*# Mg-2.4
[**2141-4-25**] 02:21AM BLOOD Albumin-2.3* Calcium-7.0* Phos-3.5#
Mg-2.1
[**2141-4-25**] 05:00PM BLOOD Albumin-2.6* Calcium-7.4* Phos-2.6*
Mg-2.4
[**2141-4-25**] 10:46PM BLOOD Calcium-7.7* Phos-2.7 Mg-2.6
[**2141-4-26**] 04:46AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.7*
[**2141-4-27**] 03:24AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.5
[**2141-4-29**] 05:45AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.0
[**2141-4-30**] 05:50AM BLOOD Calcium-7.4* Phos-4.7* Mg-1.9
[**2141-5-1**] 05:52AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.0
[**2141-4-29**] 05:45AM BLOOD Free T4-0.92*
[**2141-4-27**] 03:24AM BLOOD TSH-0.20*
[**2141-4-29**] 05:45AM BLOOD TSH-1.8
[**2141-4-25**] 05:00PM BLOOD Vanco-8.8*
[**2141-4-24**] 09:48AM BLOOD Lactate-7.2*
[**2141-4-24**] 11:31AM BLOOD Lactate-3.9*
[**2141-4-24**] 09:58PM BLOOD Lactate-4.9*
[**2141-4-25**] 02:50AM BLOOD Lactate-3.8*
Brief Hospital Course:
This is a 58 year-old Male who initially presented with 3-days
of left forearm swelling, redness and pain associatd with fevers
for one day. He noted the onset of bilateral axilla erythema for
2-weeks after having upper respiratory symptoms including
congestion and cough. Three days prior to presentation, the
patient developed severe left arm pain and erythema, targeting
elbow and forearm, associated with intermittent paresthesias of
the left hand. He then reported the onset of high fever, nausea
and vomiting on the night prior to arrival. He presented to the
[**Hospital1 18**] ED where his labs were notable for a lactate of 7.2, he
had evidence of mild renal insufficiency with a creatinine of
1.8 and a WBC to 27.5. He received 4L of IVF's. X-ray of the
extremity was performed and was negative for gas. CT of the
extremity was performed which showed deep fascial edema
concerning for impending compartment symdrome, without gas.
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative periods and transitioned to PO
narcotic medication with adequate pain control on POD#9 from his
initial surgical procedure. The patient remained neurologically
intact and without change from baseline. The patient remained
alert and oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. He did,
however, develop intermittent, paroxysmal atrial fibrillation
following his first surgical procedure with rapid ventricular
repsonse refractory to medical treatment initially with
Lopressor and Diltiazem. He Cardiology had been consulted,
recommending an Amiodarone gtt which was discontinued following
his initial procedure and following an oral loading dose. He
remains on Amiodarone, and will follow-up with cardiology as an
outpatient. He had no further episodes of atrial fibrillation
from POD#[**5-22**]. Vitals signs were closely monitored via telemetry.
He remained hemodynamically stable throughout his stay.
RESPIRATORY: The patient was extubated POD#1 from his initial
procedure, successfully. The patient had no episodes of
desaturation or pulmonary concerns. The patient denied cough or
respiratory symptoms. Pulse oximetry was monitored closely and
the patient maintained adequate oxygenations. He was extubated
without issue following his washout and debridements in the
operating room.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#0 from
each procedure, again being made NPO past midnight for his
following procedure. The patient experienced no nausea or
vomiting. The patient was transitioned to a regular diet on
POD#[**8-22**] and IV fluids were discontinued once adequate PO intake
was established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was not
required and the patient was able to successfully void without
issue. The patient's intake and output was closely monitored for
> 30 mL per hour output. The patient's creatinine was 1.8, with
evidence of acute renal insufficiency on admission, however,
this improved with adequate hydration. His creatinine normalized
to 0.9 prior to discharge.
HEME: The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from their
incision. His hematocrit remained stable.
ID: The patient was admitted with concerns of acute compartment
syndrome versus necrotizing fasciitis. For this, he was
emergently brought to the operating room for left forearm
fasciotomy and VAC placement. At the time of his procedure,
infectious disease physicians were notified and he was
empirically begun on IV Vancomycin, Clindamycin and Zosyn. His
OR wound cultures initially speciated Beta Streptococcus group
A, as did all following cultures. He was taken to the operating
room on HOD#2, 3, 5 and 7 for subsequent debridements and
washouts with a final procedure on [**2141-5-1**] consisting of a left
forarm I&D, split thickness skin graft from the left thigh and
VAC placement. Infectious disease specialists continued to
follow the patinet, as his antibiotics were tapered to IV
Ceftriaxone 2 g IV Q24 hours. His WBC on admission was 27 and
fell steadily to around a WBC 12 prior to discharge. Serial arm
and hand examinations were continuously performed, yielding
steady improvement. His arm remained elevated, in a volar
resting splint and sling, in an elevated position at all times.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. The patient was encouraged to utilize incentive
spirometry, ambulate early and was discharged in stable
condition.
Medications on Admission:
nexium
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): Apply to underarms.
Disp:*1 Bottle* Refills:*1*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 5 days: last dose
[**2141-5-8**].
Disp:*5 solutions* Refills:*0*
4. 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.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*1*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever: Max 12/day. Do not exceed
4gms/4000mgs of tylenol per day.
9. Outpatient Lab Work
Please draw the following labs on [**2141-5-8**]:
1) CBC w/diff
2) BUN/Cr
3) LFTs
Please fax results to Dr.[**Name (NI) 23346**] office, fax #: [**Telephone/Fax (1) 76019**]
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Necrotizing fasciitis, left arm: BETA STREPTOCOCCUS GROUP A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your wound vac to your left arm skin graft site should stay
intact until Tuesday, [**5-9**], when you. Please keep suction
at 125 mmHg.
.
You may maintain your left arm in a sling for comfort and you
should always wear your orthoplast splint. You should continue
to actively move your fingers so that they don't become stiff.
.
You should continue to leave your left thigh donor site open to
air to dry it out. The yellow dressings should stay in place
and dry out like a scab. Do not get this area wet until cleared
by Dr. [**Last Name (STitle) 5385**].
.
Please follow up with your primary care physician within one
week of discharge. You had an occurrence of atrial fibrillation
while an inpatient, and you are being discharged on Lopressor.
This needs to be managed by your PCP.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Your antibiotic will be given IV until [**2141-5-8**] when you will
receive your last dose.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical sites, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 5385**]: ([**2141**]
for this Tuesday, [**2141-5-9**] at 3:30PM to have wound vac dressing
removed. Dr. [**Last Name (STitle) 5385**] is located at:
[**Apartment Address(1) 76020**]
[**Location (un) 55**], [**Numeric Identifier 3883**]
.
Please schedule a follow up with your Primary Care Provider to
[**Name9 (PRE) 76021**] the need for your 'lopressor' medication used to help
prevent the recurrence of 'atrial fibrillation' that you
experienced while you were in the hospital. [**Last Name (LF) 76022**],[**First Name3 (LF) 8694**] C.
[**Telephone/Fax (1) 2115**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
ICD9 Codes: 5849, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4491
} | Medical Text: Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-14**]
Date of Birth: [**2072-3-4**] Sex: F
Service: VSU
CHIEF COMPLAINT: Right thigh wound.
HISTORY OF PRESENT ILLNESS: This 70-year-old female, with
known peripheral vascular disease and is status post multiple
vascular surgeries, presents to Dr.[**Name (NI) 1392**] office with a
right knee-thigh pain since [**2142-11-10**], and acute
right thigh drainage today, bloody in character. Outside work-
up included knee films which were negative, intra-articular
cortisone injection without improvement to the knee, an MRI
of the spine which demonstrated disk disease. Patient was to
get an epidural injection, but this was not done secondary to
her current symptoms. Patient denies fevers, chills, sweats.
She denies glucose changes. She was seen by her primary care
physician and started on ciprofloxacin 500 mg on [**2142-12-28**]. There had been no changes in the right knee pain. She
is now admitted for post incision and drainage in the office
for IV antibiotics and wound care.
PAST MEDICAL HISTORY:
ALLERGIES: Benadryl--manifestations unknown; aspirin--GI
bleed.
MEDICATIONS: Protonix 40 mg once daily, Zoloft 50 mg once
daily, Lasix 80 mg once daily, lisinopril 20 mg once daily,
Lipitor 80 mg once daily, warfarin 3 mg on Tuesdays,
Thursdays, Saturdays and Sundays, warfarin 2 mg on Monday,
Wednesday and Friday, Humulin-N 50 units q. a.m. and Humulin-
N 35 units at bedtime, with a Humalog sliding scale before
meals and at bedtime, Slow-Iron daily.
ILLNESSES: Include coronary artery disease status post
coronary angioplasty with stenting of the right coronary
artery in [**2141-12-16**], history of congestive heart failure--
compensated, history of hypertension--controlled, history of
hypercholesterolemia on a statin, history of upper GI bleed
secondary to aspirin--asymptomatic, history of MRSA sepsis in
[**2142-2-13**].
PREVIOUS SURGERIES: A cholecystectomy in [**2096**],
aortobifemoral bypass in [**2128**] with a right AK popliteal
bypass in [**2134**], bilateral right and left femoral popliteals
in [**2127**], a fem-fem bypass with a right SFA endarterectomy in
[**2127**], removal of the fem-fem bypass with vein patch
angioplasty to the PFA in [**2128**], a redo common femoral BK [**Doctor Last Name **]
with 8-mm PTFE in [**2139-11-15**], also a thrombectomy of the
common femoral artery at the same time, a left temporal
biopsy in [**2141-3-16**] which was negative, a jump graft of
right fem [**Doctor Last Name **] to BK [**Doctor Last Name **] with PTFE, and endarterectomy of the
popliteal artery in [**2142-2-13**].
SOCIALLY: The patient lives with her husband. She ambulates
with a cane. She denies smoking or alcohol use.
PHYSICAL EXAM: VITAL SIGNS: 138/70, 68, 16, O2 sat 96% in
room air. HEENT EXAM: There is no JVD, a left carotid bruit,
carotids are palpable 2 plus bilaterally. Lungs are clear to
auscultation. Heart has a regular rate and rhythm without
murmur, gallop or rub. Abdominal exam is soft, nontender,
bowel sounds x4. There are no bruits or masses. Peripheral
vascular exam: The right thigh is with a 2x2 opening with
surrounding erythema and warmth to palpation. Pulse exam
shows on the right radial artery palpable 1 plus, femoral 2
plus, DP and PT palpable at 2 plus. On the left, the radial,
femoral, dorsalis pedis, posterior tibial are all palpable at
2 plus. NEUROLOGICAL EXAM: Patient is oriented x3, nonfocal.
HOSPITAL COURSE: The patient was admitted to the vascular
service. She was placed on bed rest. Wound cultures were
obtained. Routine labs were obtained. Antibiotics of
vancomycin, levofloxacin and Flagyl were instituted. Blood
cultures and urine cultures were obtained. For diabetes, we
continued her current regime. Hemoglobin A1C was obtained. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult was obtained. A urinalysis was done to rule
out a UTI. The patient was continued on her antihypertensive
medications. Electrocardiogram was checked initially with no
acute changes. Coumadinization was held in anticipation for
potential further surgical intervention versus diagnostic
procedure. Initial swab grew oxacillin resistant staph, coag-
positive, heavy growth. Sensitivities to Bactrim were
requested, and this was sensitive to vancomycin, Bactrim,
tetracycline and gentamicin. The anaerobe cultures were no
growth. Blood cultures: Initial cultures grew [**1-17**] Staph coag-
positive, oxacillin resistant. The patient's repeated blood
cultures x3 were no growth and finalized. The patient had
urine cultures. She required several samplings until we
obtained an adequate urine for culture which was no growth.
On hospital day #2, patient complained of chest discomfort.
She was alert. Vital signs were stable. EKG during chest pain
showed no acute changes. There was some mild ST depression in
III, AVF, V1 and V2, as compared with the EKG on [**2142-3-18**]. Nitroglycerin relieved the symptoms within 3 minutes. A
repeat EKG was without change.
[**Last Name (un) **] followed the patient during her hospitalization for
diabetic management. Her hemoglobin A1C was 7.9. Infectious
disease was consulted for recommendations for appropriate
antibiotic therapy and length of therapy. Patient was
continued on current therapy. A vascular lab ultrasound
secondary to carotid disease and no follow-up in 2 years.
This showed a moderate plaque in the right internal carotid
artery and the left, the right being greater with narrowing
of the right of 40-59%, and on the left 60-69%. There was
normal left vertebral antegrade flow, and the right vertebral
was occluded. Patient had an MR of the lumbar spine obtained.
There were no abnormal signals within the vertebral bodies.
There was some loss of signal in L3-L4, L4-5, L5 and S1.
Intervertebral disk indicates some degenerative changes with
minimal loss of height in 3 and 4, with no significant
bulging of the disk. Significant disease was noted in L5 and
S1 with intervertebral disk loss and focal right base
protrusion and herniation into the spinal canal causing
displacement and compression of the S1 nerve root sleeve.
There was mild compression of the thecal sac at this level.
There was no abnormal signal within the disk to suggest
diskitis. The vertebral bodies demonstrate normal signal.
There is no evidence for abscess, or other fluid collections.
The patient's aortobifemoral graft was identified.
The patient had an MRA of the aorta and pelvic vessels and
the right leg vessels. The abdominal aorta was unchanged in
appearance. Renal arteries: Right there were 2, on the left
it was singular and were patent. The celiac and superior
mesenteric were patent. Aortobifemoral bypass was widely
patent throughout, originating from the distal infrarenal
aorta proximally and midway between the origin of the renal
arteries and the native bifurcation. The graft shows no
narrowing into its anastomosis with the common femoral
arteries bilaterally, where there are clip artifacts. There
are no collaterals to suggest high-grade stenosis. The native
distal aorta to graft origin remains patent with some
irregularity. There was irregularly, as well, within the
bilateral common iliacs which remain patent until the level
of the bifurcation. No internal iliac arteries could be
identified. On the right lower extremity, there is a
pseudoaneurysm of the right common femoral just beyond the
insertion to the right aortobifemoral artery graft which has
increased in size. It now measures 13-mm in diameter and 60-
mm in length. Previously, it was a 9x16. The profunda on the
right is patent. The right fem above-knee popliteal graft
shows mild narrowing proximally just distal to the
pseudoaneurysm, and it returns to normal caliber within the
proximal thigh. It is widely patent to the distal thigh where
the jump graft originates. Jump graft from the fem above-knee
popliteal graft to below-knee popliteal graft is completely
thrombosed. Throughout its entire extent, there is extensive
enhancement surrounding the occluded graft which occluded
distally at its anatomosis to below-the-knee popliteal and
medially at its origin which extends into the surface of the
skin where the patient's ulcer is located. This is highly
suggestive of infectious cause with an infected graft.
It is uncertain, however, whether these areas are infected,
and which have reactive enhancement from thrombosis. There is
no drainable fluid collection seen within this area. The
abnormal enhancement extends around the femoral above-knee
popliteal graft at the site of the jump graft origin, and the
femoral above-knee popliteal graft remains patent. At this
area through moderately narrowed proximally 50% to the
femoral, above-knee popliteal graft was patent to its
anastomosis with the above-knee popliteal, and the above-knee
popliteal artery is patent to the top of the prior
pseudoaneurysm just beyond the femoral condyle. Collaterals
are not well seen around the jump graft or the above-knee
popliteal artery occlusions. The anterior tibial and
posterior tibial arteries appear to be patent. The anterior
tibial and common peroneal and posterior tibial trunk is
reconstituted by collaterals. The anterior tibial does not
fill the DP. However, the posterior tibial does remain patent
into the foot. The peroneal artery is minimally patent
proximally, and does not extend beyond the midcalf. Left
lower extremity, the aortofemoral graft is patent throughout
its anastomosis with the femoral artery. The origin of the
profunda femoris is patent; however, there is a small
pseudoaneurysm at its origin measuring 8-mm in diameter which
is slightly increased in size from prior study. The left fem
below-knee popliteal artery graft is widely patent throughout
its course without evidence of focal stenosis. There is mild
narrowing of the native left anterior tibial artery without
high-grade stenosis. The common peroneal, posterior tibial
trunk is widely patent, and the posterior tibial artery is
widely patent throughout its course. The peroneal artery is
patent proximally and extends to the distal calf where it
gives off some collateral branches to both posterior tibial
and anterior tibial arteries. The anterior tibial artery
fills the dorsalis pedis which is diminutive but patent. The
posterior tibial artery fills plantar arteries with a
dominant lateral plantar branch that is patent. There is
edema within the vastus lateralis bilaterally and adjacent
muscles that is nonspecific. There is no other significant
muscle edema except for in the areas around the affected jump
graft and packed cavity.
Patient was evaluated by the cardiology service for
perioperative risk assessment. They felt that a Persantine-
MIBI was not indicated at this time, as there is probably
100% chance that it would be positive. Its only value would
be to determine size of ischemic defect, probably not small,
from EKG changes. The patient is at a high risk, but surgery
is unavoidable. Recommendations to transfuse to correct
anemia for hematocrit greater than 30, maintain her systolic
pressure in 120s-130s, maintain pulse rate in the 60s or
less, and proceed with surgery known at a higher risk.
Patient underwent on [**2143-1-7**] an excision of the PTFE
jump graft and wound debridement. She tolerated the procedure
well and was transferred to the PACU in stable condition. She
required 2 units of packed red blood cells for a
postoperative hematocrit of 21.4. She remained
hemodynamically stable and was transferred to the VICU for
continued monitoring and care.
Postoperative day 1, post-transfusion crit was 22.6.
Initially ran [**Company 5249**]-max of 100.1-99.9. The initial wound was
repacked and dressed. Patient remained in the VICU, Swan'd,
transfused 2 units of packed red blood cells. The glycemic
control was excellent. Serial CKs were flat. Troponins were
0.18, 0.18, 0.23. EKG was without further change. Patient was
continued on current management. Patient continued to be
followed by [**Last Name (un) **] service. Patient required IV nitroglycerin
for systolic hypertension. Post-transfusion crit was 26.9.
Patient's diet was advanced as tolerated. Diuresis was
continued. Patient was continued on antibiotics and remained
in the VICU for continued monitoring and care.
On postoperative day 3, T-max was 1003. The patient's Swan-
Ganz was converted to a triple-lumen. Diuresis was continued.
She was transfused another unit of packed red blood cells,
and electrolytes were repleted. Post-transfusion crit was
30.6. Diuresis was continued with IV Lasix. Reglan was begun
p.o. The patient was continued to be followed by infectious
disease.
Postoperative day 4, the levofloxacin and Flagyl were
discontinued. Patient continued to be diuresed. Her
hematocrit was 33.0 and stable. Her exam was unremarkable.
She had a Dopplerable DP and PT on the left, and a
Dopplerable DP on the right. Ambulation to chair was begun.
She was tolerating p.o.'s. IV fluids were Hep-Locked. She had
an excellent urinary output. Foley was discontinued at
midnight. She continued to be diuresed. O2 sats were
monitored, and O2 weaned. With adjustments in her insulin
dosing, her hyperglycemia improved. Final recommendations
from ID was that the patient should continue for a total of 6
weeks of IV vancomycin from the date of removal of the graft,
which was [**1-7**]. The vanco trough should be monitored
weekly along with a CBC, diff, BUN and creatinine. The trough
goal is [**10-4**]. These results should be faxed to the
infectious disease department at [**Telephone/Fax (1) 1419**]. Patient has
been instructed to follow-up with infectious disease clinic
in [**Month (only) 958**], and the number has been given to the patient to
call for an appointment time. A PICC line was placed on
[**2143-1-11**] for continued antibiotic therapy.
Remainder of the hospital course was unremarkable. The
patient was discharged to rehab in stable condition.
DISCHARGE MEDICATIONS: Acetaminophen 325 mg tablets [**12-17**] q. 4-
6 h. p.r.n., hydrocodone/acetaminophen 5/500 mg tablets [**12-17**]
q. [**3-21**] h. p.r.n., Zoloft 50 mg daily, amlodipine 5 mg daily,
atorvastatin 80 mg daily, Citalopram 5 mg tablets [**12-17**] at
bedtime p.r.n. as needed, Protonix 40 mg once daily,
Lopressor 50 mg t.i.d., Reglan 5 mg before meals and at
bedtime, hydromorphone 2 mg tablets [**12-17**] q. [**2-16**] h p.r.n.
severe pain, warfarin 3 mg daily. Maintain an INR between 2.0-
3.0 for graft patency. Patient's PICC line should be flushed
according to protocol of the hospital or VNA service that the
patient's care is under. Patient will continue vancomycin at
750 mg q. 12 h. for a total of 6 weeks, starting from [**2143-1-7**] to [**2143-2-18**]. Patient's NPH Insulin we will
continue at 42 units in the morning and 20 units at bedtime.
Humalog sliding scale as directed. Please see enclosed scale.
DISCHARGE DIAGNOSES: Methicillin resistant Staphylococcus
aureus right wound graft infection, Methicillin resistant
Staphylococcus aureus bacteremia, blood loss anemia transfuse
corrected, history of coronary artery disease status post
percutaneous transluminal coronary angioplasty with stenting
with the right coronary artery in [**2141-12-16**], history of
congestive heart failure--compensated, history of
hypertension--controlled, history of hypercholesterolemia on
statins, history of Methicillin resistant Staphylococcus
aureus sepsis previously, history of peripheral vascular
disease and multiple bypasses, history of gastrointestinal
bleed secondary to aspirin, history of gallbladder disease
status post cholecystectomy.
MAJOR SURGICAL PROCEDURES: Debridement of the right leg
wound and excision of infected jump graft on [**2143-1-7**], peripherally inserted central catheter line placement
on [**2143-1-11**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2143-1-11**] 14:12:49
T: [**2143-1-11**] 15:57:06
Job#: [**Job Number 31545**]
ICD9 Codes: 2851, 7907, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4492
} | Medical Text: Admission Date: [**2188-7-11**] Discharge Date: [**2188-7-31**]
Date of Birth: [**2135-11-25**] Sex: M
Service: MICU/Acove
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male who is a nursing home resident with a history of a
multi-system atrophy, right DVT and recent aspiration
pneumonia. He presents with an episode of hematuria from a
longstanding Foley which was recently removed two days prior
to admission. In addition, he had a meatal tear noted and
bleeding from the laceration was noted and he was brought to
[**Hospital1 69**] for further management
of the hematuria. Also of note there were blood clots
surrounding the meatus and clots in the urine and they were
unable to replace the Foley at that time. On admission he
also has had increasing sizes of his sacral pressure ulcers
which despite topical treatment have increased in size and
depth. Also of note, he has recently completed a 10 day
course of Levo/Flagyl on [**7-9**] for aspiration pneumonia. He
has a history of multiple aspiration pneumonias.
PAST MEDICAL HISTORY: Multisystem atrophy, dysphagia, he is
not a G tube candidate per patient's previous wishes. Benign
prostatic hypertrophy. Diabetes mellitus diet controlled.
Distant history of hypertension. Chronic obstructive
pulmonary disease. History of schizophrenia, currently off
psych meds for multiple months. Right femoral DVT in [**2187**],
in [**Month (only) 956**]. Depression.
MEDICATIONS: On admission included Celexa 20 mg po q day,
Lovenox 100 mg subcu [**Hospital1 **], Permax 1.5 mg po bid, Tylenol #3
prn, Multivitamin, ProMod tid, Trazodone 100 mg q h.s.,
Vitamin C 500 mg [**Hospital1 **], Zinc 220 mg three times per week.
ALLERGIES: Patient is allergic to Haldol which causes extra
pyramidal symptoms.
SOCIAL HISTORY: Patient is a resident of the [**Hospital3 36255**] Home. His guardian is [**Name (NI) **] [**Name (NI) 36260**], [**Telephone/Fax (1) 36257**].
PHYSICAL EXAMINATION: Patient is ill appearing, slightly
tachypneic on admission. His vital signs on admission were
blood pressure of 116/66, temperature 100, pulse 133, satting
91% on room air. HEENT: Bilateral conjunctival injection
with moist oropharynx, nasopharynx. On pulmonary exam he has
coarse rhonchi throughout his entire lung fields with upper
and lower chest congestion. Cardiovascular is regular rate
and rhythm with normal S1 and S2. Abdomen is soft,
nontender, non distended, positive bowel sounds and no
masses. GU exam, he has traumatic hypospadias with blood
surrounding the urethral meatus. On dermatologic exam he has
large, greater than 6 cm stage IV sacral ulcers. Neuro exam,
patient opens his eyes, was non verbal and lethargic. He is
extremely stiff throughout and has severe contracture in his
extremities.
LABORATORY DATA: On admission, white count 15.7 with 88%
neutrophils. His hematocrit was 35.1 which is his baseline
and his platelet count was 597,000. His BMP with sodium 140,
potassium 4.1, chloride 105, CO2 24, BUN 20, creatinine 0.5
and glucose 87 with an albumin of 2.8. His lactate was
normal at 1.1. Coags were notable for an INR of 1.4, PT 14.0
and PTT 23.9. Initial urinalysis showed that patient had
specific gravity of 1.025 with positive nitrites, negative
leukocyte esterase and [**2-19**] white blood cells with occasional
bacteria and [**5-26**] red blood cells with large blood. Arterial
blood gas on admission was 7.44, 34 and 64, PO2 on three
liters of oxygen.
HOSPITAL COURSE: The patient initially was brought to the
hospital given his episode of hematuria noted after removal
of the Foley. During his admission in the Emergency Room he
was noted to become hypotensive with a blood pressure in the
50's/30's as well as tachycardic with a rate to the 130's.
He was started on Zosyn and Vanco at this time and had a
chest x-ray which showed that he had a new left lower lobe
opacity. He did not require pressors for his hypotension.
The patient then was noted to have hypoxemic respiratory
failure and was intubated on [**7-11**] for this. He had
difficulty and was admitted to the medical care intensive
unit. He had difficulty with extubation and weaning from the
ventilator due to high levels of copious secretions. Also
during the MICU course he continued to spike fevers despite
being treated with Vancomycin and Zosyn. He had sputum
cultures which grew out Klebsiella which were resistant to
all antibiotics tested except for Zosyn and Imipenem. Also
it was noted that he had yeast in the urine and Diflucan was
started for this. In addition, patient was seen by the GU
service during his MICU admission and they recommended
possible placement of a suprapubic catheter due to his
decubitus ulcers, history of hypospadias and history of
urethral meatal tear. NG tube was placed and patient was fed
with NG tube feedings and was also supplemented with Vitamin
C and Zinc for improved wound healing. The patient was
extubated on [**7-23**] after an extended intubation course due to
significant amount of secretions. The patient's secretions
eventually had decreased and patient was transferred to the
Acove service. The patient, after he was extubated, had a
repeat episode of tachypnea on [**7-27**] where his respiratory
rate was in the 40's and elevated heart rate. His O2 sats
were dropping. He spiked a fever to 100.8 and chest x-ray
showed repeat right lower lobe infiltrate. Arterial blood
gas showed an AA gradient of approximately 39. At this point
he had still been on Zosyn and Vancomycin which had been
started upon his admission. It was discussed with ID who
recommended a 21 day course treatment of the Zosyn and Vanco.
Tube feeds were stopped at this point, given it was felt that
he had an aspiration pneumonitis. On the following day the
patient had multiple episodes of desaturation with PCO2 to
the 60's for approximately 20 minutes and noted to have
extremely thick secretions upon suctioning. Prior to this,
aggressive chest physical therapy had been continued. The
patient also was noted to be relatively hypotensive with a
systolic blood pressure over the 90's later that day. Given
the patient's worsening respiratory status, it was discussed
with the guardian about patient's overall prognosis. The
patient's guardian believes the importance of keeping the
patient comfortable during the remainder of his hospital
course as well as future treatments. At this point it was
decided that patient would have focus on his comfort
measures. The patient's NG tube was removed and afterwards
the patient felt more comfortable subjectively. In addition,
patient was started on pain medications for pain control.
Also patient's other medications such as antibiotics were
stopped as it was felt that if patient were to have a septic
compromise, it would be more gentler and kinder than a
respiratory compromise. The patient at this point appears
comfortable, in no acute distress and previously when he had
been turned he expressed signs of discomfort such as moaning,
but currently feels comfortable upon position changes.
Regarding patient's pain medications, patient initially was
started on IV Morphine at 2 mg per hour and appeared
comfortable on this medication. His medications were changed
over to po Roxanol sublingual q 2 hours. If patient is to
have continuing breakthrough pain, we plan to decrease this
interval to q 1 hour. It is important that patient have a
continuos pain medication so he does not have breakthrough
pain. In addition, the Scopolamine patch was added to help
decrease the patient's secretions. Also, Fentanyl patch was
added to the patient's pain regimen.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Patient to be discharged to nursing home.
DISCHARGE DIAGNOSIS:
1. History of multisystem atrophy.
2. History of multiple aspiration pneumonia.
3. History of stage 3 and 4 pressure ulcers.
DISCHARGE MEDICATIONS: Roxanol 4 mg sublingual po q 2 hours,
Fentanyl patch 50 mcg q 72 hours, Scopolamine patch [**12-19**]
patches q 72 hours, Tylenol 325 mg to 650 mg per rectum prn
fever.
[**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**]
Dictated By:[**Last Name (NamePattern1) 27308**]
MEDQUIST36
D: [**2188-7-31**] 10:26
T: [**2188-7-31**] 10:34
JOB#: [**Job Number 36261**]
ICD9 Codes: 0389, 5070, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4493
} | Medical Text: Admission Date: [**2101-7-20**] Discharge Date: [**2101-8-16**]
Date of Birth: [**2021-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea at rest
Major Surgical or Invasive Procedure:
- [**2101-7-20**] Aortic valve replacement (23mmSt. [**Male First Name (un) 923**] Epic Supra
tissue), and Three Vessel coronary artery bypass grafts(left
internal mammary artery to left anterior descending artery with
saphenous vein grafts to diagonal and PDA)
- [**2101-7-30**] Exploratory laparotomy, Lysis of adhesions, Repair of
enterotomy, Placement of gastrojejunostomy tube
History of Present Illness:
This is a 79 year old white male with known coronary artery
disease and severe aortic stenosis who presented to [**Hospital1 25157**] with decompensated congestive heart failure, a
non STEMI and acute renal insufficiency. After undergoing
extensive evaluation he [**Hospital 25158**] transferred to [**Hospital1 18**] for high
risk cardiac surgical intervention. On admission he remained
extremely short of breath at rest with complaints of 3 pillow
orthopnea and mild pedal edema. He denied chest pain and
syncope. He admitted to a single presyncopal episode several
weeks ago but none since. He remains on a diuretic with only
mild relief in symptoms. Renal function prior to discharge did
improve to a creatinine of 1.0.
Past Medical History:
- Aortic Stenosis, Mitral Regurgitation
- Coronary Artery Disease, Ischemic Cardiomyopathy
- Bare Metal Stent [**2097-12-24**] to Circumflex(Vision Stent)
- Prior Inferior Wall MI [**2084**]
- History of Sustained Ventricular Tachycardia
- AICD/PPM in [**2098-2-22**](Guidant Model T125/Guidant Lead 0158)
- History of TIA/Stroke in [**2088**], s/p TPA therapy
- History of Abd Aortic Aneurysm, - Enodvascular Repair of Abd
Aortic Aneurysm [**2099**]
- History of Acute Renal Failure
- Diverticular Disease, s/p Colectomy
- Anemia
- Varicose Veins
Social History:
Denies smoking tobacco but does chew cigars daily. There is no
history of alcohol abuse, patient drinks one [**Location (un) **] every two
weeks. Patient is a janitor at [**Hospital6 1109**].
Family History:
Denies premature coronary artery disease. Four brothers died of
MI in their 80's.
Physical Exam:
Pulse: 70 Resp: 16 O2 sat: 100%
B/P Right: Left: 117/86
General: Elderly male in no acute distress. Mildly SOB
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+
bilaterally
Varicosities: Right GSV varicosed. Left GSV appears OK
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit: soft transmitted murmurs noted
Pertinent Results:
[**2101-7-20**] Intra operative TEE:
PREBYPASS
A left-to-right shunt across the interatrial septum is seen at
rest. A small secundum atrial septal defect is present. The left
ventricular cavity is severely dilated. There is severe regional
left ventricular systolic dysfunction with akinesis of the
inferior and inferoseptal walls and hypokinsesis of the
remaining segments. Overall left ventricular systolic function
is severely depressed (LVEF <20 %). Right ventricular chamber
size is normal. with mild global 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. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen.
POSTBYPASS
The patient is receiving epinephrine infusion at 0.05 ucg/kg/min
The LV is marginally improved in the setting of inotropes. RV
function now appears normal. There is a well seated, well
functioning bioprosthesis in the aortic postion. There is trace
perivalvular AI. The MR is now trace to mild.
.
[**2101-7-30**] Postoperative TEE:
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter .A
bioprosthetic aortic valve prosthesis is present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.Mild to moderate mitral regurgitation present. There
is a small pericardial effusion. LVEF is 20-25% with Global
hypokinesis. Inferior and inferoseptal wall is akinetic. The
septal motion is dyssynchronous.
.
[**2101-7-27**] Flouroscopy:
Uncomplicated ultrasound and fluoroscopically guided
double-lumen
PICC line placement via the right basilic venous approach. Final
internal
length is 37 cm, with the tip positioned in SVC.
.
POSTOP BLOOD WORK:
[**2101-8-15**] WBC-11.0 RBC-2.97* Hgb-8.6* Hct-26.0* RDW-14.9 Plt
Ct-456*
[**2101-8-13**] WBC-10.3 RBC-3.01* Hgb-8.9* Hct-26.1* RDW-14.8 Plt
Ct-364
[**2101-8-11**] WBC-12.9* RBC-2.83* Hgb-8.5* Hct-25.3* RDW-15.0 Plt
Ct-321
[**2101-8-10**] WBC-15.4* RBC-3.06* Hgb-9.1* Hct-27.4* RDW-15.0 Plt
Ct-293
[**2101-8-9**] WBC-17.6* RBC-3.24* Hgb-9.5* Hct-29.7* RDW-15.4 Plt
Ct-303
[**2101-8-8**] WBC-12.7* RBC-3.18* Hgb-9.2* Hct-29.2* RDW-15.3 Plt
Ct-265
[**2101-8-9**] WBC-17.6* RBC-3.24* Hgb-9.5* Hct-29.7* RDW-15.4 Plt
Ct-303
[**2101-8-6**] WBC-12.2* RBC-3.27* Hgb-9.7* Hct-29.7* RDW-15.2 Plt
Ct-207
[**2101-8-3**] WBC-17.4* RBC-3.43* Hgb-10.0* Hct-29.7* RDW-15.1 Plt
Ct-147*
[**2101-8-1**] WBC-31.6*# RBC-3.67* Hgb-10.9* Hct-32.4* RDW-15.0 Plt
Ct-144*
.
[**2101-8-16**] 05:30AM BLOOD PT-17.0* INR(PT)-1.5*
[**2101-8-15**] 10:24AM BLOOD PT-18.7* INR(PT)-1.7*
[**2101-8-14**] 05:54AM BLOOD PT-23.6* INR(PT)-2.2*
[**2101-8-13**] 05:04AM BLOOD PT-28.4* PTT-28.7 INR(PT)-2.7*
[**2101-8-12**] 02:22PM BLOOD PT-32.6* INR(PT)-3.2*
[**2101-8-11**] 05:45AM BLOOD PT-26.9* INR(PT)-2.6*
[**2101-8-10**] 08:15AM BLOOD PT-29.3* INR(PT)-2.8*
[**2101-8-9**] 09:20AM BLOOD PT-32.7* INR(PT)-3.2*
[**2101-8-8**] 06:20AM BLOOD PT-37.4* INR(PT)-3.8*
[**2101-8-7**] 05:10AM BLOOD PT-35.2* PTT-31.3 INR(PT)-3.5*
[**2101-8-6**] 01:41AM BLOOD PT-28.0* PTT-29.7 INR(PT)-2.7*
[**2101-8-5**] 02:20AM BLOOD PT-23.8* PTT-31.4 INR(PT)-2.2*
[**2101-8-4**] 06:26AM BLOOD PT-21.4* PTT-29.6 INR(PT)-2.0*
[**2101-8-3**] 02:02AM BLOOD PT-18.9* PTT-33.2 INR(PT)-1.7*
[**2101-8-1**] 01:47AM BLOOD PT-16.8* PTT-32.3 INR(PT)-1.5*
.
[**2101-8-16**] Glucose-133* UreaN-35* Creat-1.0 Na-139 K-3.9 Cl-102
HCO3-30 [**2101-8-14**] Glucose-97 UreaN-36* Creat-1.1 Na-139 K-3.4
Cl-98 HCO3-35*
[**2101-8-12**] Glucose-134* UreaN-30* Creat-1.1 Na-137 K-4.0 Cl-97
HCO3-37* [**2101-8-10**] Glucose-115* UreaN-30* Creat-1.0 Na-143 K-3.8
Cl-103 HCO3-30 [**2101-8-8**] Glucose-76 UreaN-33* Creat-1.1 Na-148*
K-4.8 Cl-112* HCO3-29 [**2101-8-7**] Glucose-114* UreaN-41* Creat-1.0
Na-147* K-3.3 Cl-109* HCO3-28 [**2101-8-8**] Glucose-76 UreaN-33*
Creat-1.1 Na-148* K-4.8 Cl-112* HCO3-29 [**2101-8-6**] Glucose-108*
UreaN-50* Creat-1.0 Na-150* K-3.5 Cl-111* HCO3-32 [**2101-8-4**]
Glucose-89 UreaN-53* Creat-1.2 Na-150* K-4.0 Cl-111* HCO3-30
[**2101-7-29**] Glucose-143* UreaN-62* Creat-1.5* Na-137 K-3.4 Cl-97
HCO3-27 [**2101-7-27**] Glucose-126* UreaN-82* Creat-1.9* Na-136 K-4.3
Cl-99 HCO3-24 [**2101-7-26**] Glucose-93 UreaN-77* Creat-2.1* Na-138
K-3.4 Cl-99 HCO3-25 [**2101-7-26**] Glucose-164* UreaN-77* Creat-2.4*
Na-135 K-3.7 Cl-96 HCO3-26 [**2101-7-24**] Glucose-119* UreaN-61*
Creat-2.3* Na-130* K-3.9 Cl-95* HCO3-21*
[**2101-7-21**] Glucose-85 UreaN-17 Creat-1.0 Na-141 K-4.3 Cl-111*
HCO3-24
.
[**2101-8-8**] ALT-13 AST-26 LD(LDH)-338* AlkPhos-69 Amylase-117*
TotBili-1.4
[**2101-7-31**] ALT-8 AST-19 AlkPhos-39* TotBili-1.9*
[**2101-7-30**] ALT-18 AST-25 LD(LDH)-305* AlkPhos-71 Amylase-186*
TotBili-1.1
[**2101-7-29**] ALT-20 AST-26 LD(LDH)-280* AlkPhos-75 Amylase-234*
TotBili-1.3
[**2101-7-26**] ALT-15 AST-39 LD(LDH)-283* AlkPhos-72 Amylase-52
TotBili-1.6*
[**2101-7-25**] ALT-10 AST-37 LD(LDH)-299* AlkPhos-55 Amylase-32
TotBili-1.7*
[**2101-7-24**] ALT-9 AST-29 AlkPhos-55 Amylase-40 TotBili-1.7*
.
[**2101-8-16**] Calcium-8.4 Phos-2.7 Mg-2.1
.
Brief Hospital Course:
Mr. [**Known lastname 25159**] was admitted and underwent extensive preoperative
workup. On [**7-20**] he was taken to the Operating Room where he
underwent aortic valve replacement (23-mm St. [**Male First Name (un) 923**] Epic
Supra)and coronary artery bypass grafting x3. See operative note
for details. Post-operatively he was admitted to the CVICU
intubated and sedated on Epinephrine, Neo Synephrine and
Propofol drips. He was weaned from sedation and awoke
neurologically intact and was extubated on POD 1. His internal
pacer was interrogated and found to be working appropriately.
He weaned from Neo Synephrine on POD 1 and then Epinephrione,
but required resumption of the Epinephrine and addition of
Milrinone soon after for sagging hemodynamics ansd cardiac
output. He was reswanned, a Lasix infusion was begun to diurese
the excess fluid. Epinephrine was discontinued on POD 4, along
with the Milrinone. He continued to have marginal cardiac
output and low SVO2. Dobutamine was started at 2.5ug/kg/min
with a prompt improvement. The PA catheter was removed and he
improved gradually and diuresed well so that the Lasix infusion
was stopped. He had a period of atrial fibrillation and was
started on heparin and Coumadin.
He had an ileus with nausea and vomiting and surgery was
consulted on POD 4. He was placed NPO and over a couple of days
had worsening pain, distention and required pressors. Central
hyperalimentation was begun. An exploratory laparotomy was
performed on POD 10. Adhesions were released and a feeding tube
placed. He was extubated on [**2101-8-1**] and covered with Vancomycin,
Cefazolin and Zosyn for his surgical procedure. Trophic tube
feeds were eventually begun and advanced, hyperalimentation was
weaned and discontinued. Pressors were weaned off over that
time, he remained stable and Physical Therapy worked with him.
On [**2101-8-6**] he was transferred to the floor where Physical
Therapy continued to work with him for strength and mobility.
He cotinued to progress slowly. His diet was advanced slowly and
tube feeds were changed to clyclical 110cc/hr 5pm-6am. He
remains on calorie counts and needs encourgement.
He also has had multiple skin issues. Transplant surgery
removed some of the upper staples from his abdominal wound due
to dehisence the area was debrided and wound VAC applied for
period. He was transitioned to wet-dry dressing changes. The
area is approximately [**12-26**] inch deep and appears to be healing
well. The remaining abd wound has intact staples with some mild
lower abd erythemia and moderated serous drainge. He has 3
unroofed blisters on right foot and one large unroofed blister
dorsum of left foot. He has small ulcerated area around old CT
site. GT sutured in place with some surrounding irritation from
sutures. Per surgery his sutures and staples are to remain in
for 4-6weeks. He also has unstageable wound from coccyx to anus.
He has been followed closely by the skin care nurse. Please see
nursing page 1 for further details of wound care.
ACE inhibitor was started but discontinued secondary to
hypotension. He has remained in normal sinus rhythm with stable
BP low at times but asyptomatic. He remains on Amiodarone and
low dose beta blockade. INR was followed closely and titrated
for a goal INR between 2.0 and 2.5. Given his chronic systolic
congestive heart failure, ACE inhibitor should be resumed as an
outpatient when his blood pressure allows.
He has continued to have considerable lower extremity edema and
has been aggressively diuresed. He developed contraction
alkalosis and has been transitioned to oral diuretics for
continued diuresis. He is presently at his preop weight. Given
his heart failure, he should remain on diuretics
He was medically cleared for discharge to [**Hospital **] [**Hospital 1110**] Rehab
on postoperative day 27 for further strengtening, conditioning
and monitoring. Prior to discharge, all follow up appointments
were made with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 8051**]. Following
discharge from rehab, Dr. [**Last Name (STitle) 8051**] will manage his Warfarin
as an outpatient.
Medications on Admission:
Aspirin 81 qd, Plavix 75 qd, Simvastatin 80 qd, Metoprolol
Succinate 50mg qd, Lasix 30mg qd, Vitamin D
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily): Please hold
for HR less than 60 and/or SBP less than 95mmHg.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
titrate Warfarin for goal INR between 2.0 - 2.5.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily): Please give with Lasix. Hold if K > 4.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Chronic Systolic Congestive Heart Failure, Ischemic
Cardiomyopathy
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Postop partial small bowel obstruction s/p exploratory
laparotomy, lysis of adhesions, with placement of GJ tube
Postop Atrial Fibrillation
Postop Sacral Decubitus Ulcer
Postop Abdominal Wound
History of Inferior Wall MI [**2084**]
Mitral Regurgitation
History of Sustained Ventricular Tachycardia
History of Stroke
Diverticular Disease, prior Colectomy
Anemia
Prior Enodvascular Repair of Abdominal Aortic Aneurysm [**2099**]
s/p AICD/PPM in [**2098-2-22**](Guidant Model T125/Guidant Lead 0158)
s/p Bare Metal Stent [**2097-12-24**] to Circumflex(Vision Stent)
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with one assist
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: +3 lower ext edema
Abd wound: proximal wound inch open area good granulation
tissue, remaining wound with intact staples, distal abd wound
mild erythema and serous drainage. GT site
erythematous/irritated sutured to skin
Lower ext: 3 unroofed blisters right foot and left large
unroofed blister on dorsum of left foot, no sig erythema or
drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
.
Labs: PT/INR for Coumadin ?????? indication atrial fibrillaton
Goal INR: 2.0 - 2.5
First draw: [**2101-8-18**]
**Prior to discharge from rehab, please arrange coumadin
followup with Dr. [**Last Name (STitle) 8051**]**
Followup Instructions:
You are scheduled for the following appointments:
Cardiac Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2101-9-7**] @ 1:15 PM
PCP/Cardiologist: Dr. [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8058**]) on [**2101-8-30**] at
3:15pm
General Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 673**]): [**2101-9-1**] at
2:20pm ([**Last Name (NamePattern1) **], [**Location (un) 436**], [**Location (un) 86**], MA)
.
Labs: PT/INR for Coumadin ?????? indication atrial fibrillaton
Goal INR: 2.0 - 2.5
First draw: [**2101-8-18**]
**Prior to discharge from rehab, please arrange coumadin
followup with Dr. [**Last Name (STitle) 8051**]**
.
**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:[**2101-8-16**]
ICD9 Codes: 5849, 2760, 2875, 4280, 412, 2859, 4168, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4494
} | Medical Text: Admission Date: [**2112-6-26**] Discharge Date: [**2112-7-1**]
Date of Birth: [**2043-4-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
[**2112-6-27**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] Regent mechanical
valve)
History of Present Illness:
69 year old gentleman with a complex past medical history who
has known coronary artery disease status post angioplasty and
aortic stenosis followed by serial echocardiogram. He has
recently noticed increased dyspnea on exertion. Echo earlier
this year showed severe aortic stenosis with [**Location (un) 109**] 0.76cm2. He was
referred for a cardiac catheterization which revealed no
significant coronary disease and mild aortic stenosis. He
presents now to see if his dyspnea is related to his aortic
valve disease and if he should proceed with surgery. Of note,
pulmonary function testing and a chest CT scan were not
suggestive of any disease process which may be responsible for
his exertional dyspnea.
Past Medical History:
Aortic stenosis
Hypertension
Dyslipidemia
Diabetes type 2
Paroxysmal atrial fibrillation - Cardioversion x2
B cell lymphoma, chemo and xrt
Prostate CA
Herpes Zoster
Lung CA
Bursitis
Urinary incontinence s/p artificial sphincter
Spinal stenosis
S/P right lower lobectomy [**3-/2107**]
S/P fatty tumor removal from his back
Prostate cancer, s/p resection and radiation; remission
S/P resected bronchial carcinoid
S/P left knee arthroscopy
S/P Bilateral rotator cuff repair x 2
Social History:
Race: Caucasian
Last Dental Exam: Yesterday
Lives with: Wife
Contact: [**Name (NI) **] Phone # [**Telephone/Fax (1) 9640**]
Occupation: Semi-retired, Real estate
Cigarettes: Smoked no [] yes [X] last cigarette [**2089**] Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-26**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
No Premature coronary artery disease-father died suddenly of an
MI at age 83
Physical Exam:
Pulse: 71 Resp: 16 O2 sat: 100%
B/P Right: 125/74 Left: 125/75
Height: 5'[**09**] Weight: 220
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**1-25**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema/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 Right: - Left: -
Pertinent Results:
[**2112-6-27**] Echo: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The remaining
left ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results on this patient before
surgical incision.
POST-BYPASS: Intact thoracic aorta. Normal RV systolic function.
LVEF 50%. No oovious wall motion abnormalities withl imited
Midesophageal suboptimal views. The aortic valve is stable in
position, both leaflets open and the residual mean gradient is 8
mm of Hg.
Brief Hospital Course:
Mr. [**Known lastname 410**] was admitted the day before surgery for pre-operative
work-up and to be started on Heparin for history of atrial
fibrillation. On the following day he was brought to the
operating room where he underwent an aortic valve replacement.
Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. He was started on
betablockers, statin therapy, ASA and ace-inhibitor and diuresed
toward his pre-operative weight. He was transferred tot he
stepdown unit for ongoing post-operative care. His chest tubes
and temporary pacing wires were removed per protocol. His
couamdin therapy was resumed for atrial fibrillation. On POD#5
he was cleared for discharge to home and all appointments and
instructions were advised.
Medications on Admission:
Atenolol 100mg [**Hospital1 **]
Amlodipine 10mg daily
Folic acid 2mg daily
Lasix 20mg daily
Novolog 11 units with breakfast, 20 units with dinner
Levemir 55 units at bedtime
Lisinopril 20mg daiy
Simvastatin 40mg daily
Coumadin 2.5mg alternating with 5mg
Aspirin 325mg daily
Vitamin D3 daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
2. Simvastatin 40 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16
3 day cycles: 2.5mg, x 2 days, then 5mg x 1 day, then repeat
RX *warfarin 2.5 mg [**12-21**] tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
4. Acetaminophen 650 mg PO Q4H:PRN pain/fever
5. NovoLOG *NF* (insulin aspart) 100 unit/mL Subcutaneous tid
11 units with breakfast
11 units with lunch
17 units with dinner
6. Multivitamins 1 TAB PO DAILY
7. Levemir *NF* (insulin detemir) 100 unit/mL Subcutaneous hs
55 units hs
8. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 3 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*1
9. Oxycodone-Acetaminophen (5mg-325mg) [**12-21**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-21**] tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
10. Milk of Magnesia 30 ml PO HS:PRN constipation
11. FoLIC Acid 2 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
14. Furosemide 20 mg PO BID Duration: 7 Days
then decrease to 20mg daily ongoing
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*37
Tablet Refills:*1
15. Potassium Chloride 20 mEq PO Q12H Duration: 7 Doses
then decrease to once daily
RX *K-Tab 10 mEq 2 (Two) tablets by mouth twice a day Disp #*42
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
Past medical history:
Hypertension
Dyslipidemia
Diabetes type 2
Paroxysmal atrial fibrillation - Cardioversion x2
B cell lymphoma, chemo and xrt
Prostate CA
Herpes Zoster
Lung CA
Bursitis
Urinary incontinence s/p artificial sphincter
Spinal stenosis
S/P right lower lobectomy [**3-/2107**]
S/P fatty tumor removal from his back
Prostate cancer, s/p resection and radiation; remission
S/P resected bronchial carcinoid
S/P left knee arthroscopy
S/P Bilateral rotator cuff repair x 2
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+ lower extremity edema (left > right-chronically)
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 [**2112-7-27**] at 1:15pm in the
[**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
wound check with cardiac surgery [**Telephone/Fax (1) 170**] on [**2112-7-7**] 10am in
the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 8725**] on [**2112-7-19**] at 8:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 3314**] [**Telephone/Fax (1) 3183**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechican Aortic valve
replacement
Goal INR 2.5-3.0
First draw [**2112-7-2**]
Results to Dr. [**Last Name (STitle) 7047**] phone [**Telephone/Fax (1) 8725**]; fax [**Telephone/Fax (1) 8719**]
Completed by:[**2112-7-7**]
ICD9 Codes: 4241, 4168, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4495
} | Medical Text: Admission Date: [**2115-9-18**] Discharge Date: [**2115-10-11**]
Date of Birth: [**2056-8-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation, placement of arterial line, central line
History of Present Illness:
Ms. [**Known lastname 84698**] is a 59F with a PMH s/f chronic pain with narcotic
abuse (tramadol), remote history of ETOH abuse, and depression.
This history is taken from the patient's husband, and from the
medical record as the patient is not able to give a history
secondary to altered mental status.
Per the patient's husband, the patient has been having altered
mental status for several months now. He notes that things
progressed when she was laid off from her job as a social worker
(in a dual diagnosis center). He observed that her behavior was
more disorganized- she would put items away in the wrong place,
was sleeping more, taking longer to do things that she would
normally do quickly. Eventually she became more agitated, and
more disheveled. Mr. [**Known lastname 84698**] brought his wife to see a
neurologist this past [**Month (only) 216**] to have this worked up, where she
admitted to abusing tramadol for the first time. She reported
obtaining it illegally from the internet and taking [**8-/2056**] 50mg
pills at a time. An MRI at that time did not show any acute CVA
or other process.
On Monday ([**9-16**]) the patient's husband woke up to the sound of
his wife sounding agitated. He found her on the floor,
disheveled. He helped her back into bed, and returned to sleep.
The next day, after coming home from work, he found her in her
bed covered in feces. She was arousable to voice, and could
follow simple commands, but had slurred speech, and was
confused. An ambulance was called, and the patient was taken to
[**Hospital3 **].
At [**Hospital3 4107**] the patient was noted to have the following:
1. Thrombocytopenia: On admission, her platelet count was
11,000, and fell to 7,000 on the day of transfer. Her CBC was
otherwise normal with a WBC count of 10.7 and a HCT of 36.7.
Coagulation studies were wnl, fibrinogen 986, FDP negative.
Total bilirubin was 1.0 A smear was evaluated by the
hematologist at [**Hospital3 **], and per report, no schistocytes
were seen.
2. Leukocytosis: Elevated to 10.7 with 76% neutrophils and 15%
bands. Found to have a UTI on urinalysis, started on
levofloxacin.
3. Acute renal failure: Creatinine was initially elevated to
2.2. Urine sediment showed granular casts. This improved to 1.8
with fluid challenges. A CK was 138. FeNa was 0.15%, urine
eosinophils were negative.
4. AMS: The patient had a serum alcohol and tylenol level WNL,
as well as a negative urine toxicology. A head CT non-contrast
showed no acute abnormalities. She did admit to last using
tramadol 4 days ago, and also using her husbands ativan.
5. UTI: Urinaylysis with too many to count WBC, 4+ bacteria and
positive LES. She was started on levofloxacin 250mg IV daily
Review of systems is notable for a URI two months ago, easy
bruising, and one episode of epistaxis in the last month. Her
husband denies fevers, melena, hematochezia, hematuria. He does
note that she has had the chills.
Past Medical History:
#. Altered mental status: Time course over the past several
months. Evaluated by Neurology here. Had an MRI of the brain on
[**2115-8-21**] with chronic white matter ischemic changes, but
nothing acute.
#. History of ETOH abuse
-Sober x 28 years
#. Chronic lower back pain- secondary to lumbar spondylosis
-Reports buying tramadol illegaly over the internet and taking
15-50 50mg tablets twice weekly (in [**6-/2115**]), now reports she is
no longer using.
#. Urinary incontinence
-Over the last 5 years
-Consistent with urge incontinence
-Has had a work up with urology
#. Depression
-Has been hospitalized twice for depressive episodes
#. Nephrolithiasis
#. Hyperlipidemia
#. S/p cholecystectomy
#. OSA
Social History:
Lives at home with her husband. She worked as a program director
treating dual diagnoses of addiction/psychiatric illness,
currently laid off. Smokes [**12-1**] ppd x 40 years. H/o ETOH abuse,
sober x 28 years. Tramadol use as above.
Family History:
Sister with a CVA, mother with alzheimer's dementia and breast
CA, father with brain CA.
Physical Exam:
T=101.1... BP=127/65... HR=95... RR=22... O2=95% 6L
PHYSICAL EXAM
GENERAL: Somnolent, arousable to voice. Follows simple commands,
but nods off during exam. No apparent distress.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. No buccal petechia,
or evidence of gum bleeding. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB anteriorly
ABDOMEN: NABS. Soft, diffusely tender to deep palpation
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No petichiae, eccymoses, purpura
NEURO: Oriented to person and "hospital". Opens eyes to voice.
Glascow coma scale 13. CN 2-12 in tact. Moves extremities
spontaneously. Cannot cooperate with a full neuro exam.
Pertinent Results:
[**2115-9-18**] 07:30PM RET AUT-1.0*
[**2115-9-18**] 07:30PM FIBRINOGE-990*
[**2115-9-18**] 07:30PM FDP-10-40*
[**2115-9-18**] 07:30PM PT-10.8 PTT-21.4* INR(PT)-0.9
[**2115-9-18**] 07:30PM PLT SMR-RARE PLT COUNT-10*#
[**2115-9-18**] 07:30PM NEUTS-93.6* LYMPHS-4.9* MONOS-0.9* EOS-0.2
BASOS-0.4
[**2115-9-18**] 07:30PM WBC-7.4 RBC-4.20 HGB-12.4 HCT-36.9 MCV-88
MCH-29.5 MCHC-33.6 RDW-15.6*
[**2115-9-18**] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-9-18**] 07:30PM HAPTOGLOB-375*
[**2115-9-18**] 07:30PM ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-2.1*
MAGNESIUM-2.2
[**2115-9-18**] 07:30PM ALT(SGPT)-54* AST(SGOT)-41* LD(LDH)-423*
CK(CPK)-83 ALK PHOS-217* TOT BILI-1.3 DIR BILI-0.6* INDIR
BIL-0.7
[**2115-9-18**] 07:30PM GLUCOSE-224* UREA N-50* CREAT-1.7* SODIUM-137
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-19* ANION GAP-17
[**2115-9-18**] 07:31PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-9-19**] TSH 25
[**2115-9-20**] T4 <1.0* T3<20* calc TBG 1.21 TUptake-0.83 free T4
0.10
[**2115-10-4**] TSH 38
[**2115-10-4**] T4-2.6* T3-40* calc TBG-1.21 TUptake-0.83 T4 index-2.2*
free T4-0.31*
[**2115-9-21**] anti-TPO 124
ECHO: [**2115-9-19**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = [**9-12**] %). The right ventricular cavity is
mildly dilated with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small to moderate sized
circumferential pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Severely globally depressed left ventricular
systolic function. Small to moderate circumferential pericardial
effusion with no evidence of tamponade.
CT Head w/o Contrast: [**2115-9-19**]
There is no intracranial hemorrhage, edema, mass effect or
vascular
territorial infarction. The ventricles and sulci are normal in
size and in
configuration. Extracranial soft tissue structures are
unremarkable. The
included osseous structures reveal no fracture. The visualized
mastoid air
cells are clear. The visualized paranasal sinuses reveal a small
amount of
mucosal thickening in the maxillary sinuses bilaterally.
IMPRESSION: No acute intracranial process.
CT Chest/ Abdoman/ pelvis: [**2115-9-19**]
Endotracheal tube terminates approximately 4.5 cm above the
carina. The lungs contain dense bilateral consolidations, worst
at the lower lobe on the left and involving all lobes on the
right. Note is made of small bilateral pleural effusions. Note
is also made of a moderate pericardial effusion. Otherwise, the
heart and great vessels are notable for atherosclerotic
calcification at the aorta. Numerous mediastinal lymph nodes are
visualized, none of which appear enlarged by CT size criteria.
CT ABDOMEN WITHOUT CONTRAST:
Nasogastric tube has been repositioned and now terminates in the
stomach. Otherwise, the stomach and duodenum are unremarkable.
The spleen is 13 cm. The pancreas is unremarkable. The liver is
diffusely hypodense, consistent with the findings described on
the ultrasound. The patient is status post cholecystectomy. The
kidneys are notable for a right parapelvic cyst and left
hydronephrosis. There is no free gas or fluid in the abdomen and
note is made of a fat-containing umbilical hernia. Scattered
retroperitoneal and mesenteric lymph nodes are visualized, none
of which meet CT size criteria for pathologic enlargement.
CT PELVIS WITHOUT CONTRAST: The rectum, decompressed colon,
uterus, and
adnexa appear unremarkable. The urinary bladder contains a Foley
catheter and is collapsed. Left hydroureter extends to an
obstructive 6x5mm ureteral stone (2:103). There is no free gas
or fluid in the pelvis and there is no pelvic or inguinal
lymphadenopathy.
ECHO: [**2115-9-27**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Regional
left ventricular wall motion is normal. There is mild global
left ventricular hypokinesis (LVEF = 40-45%). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is a moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Moderate pericardial effusion without signs of tamponade.
Compared with the prior study (images reviewed) of [**2115-9-19**],
left ventricular cavity is smaller and systolic function has
substantially improved. There is less mitral regurgitation. The
other findings are similar.
MR HEAD: [**2115-10-1**]
There is no acute infarction, edema, mass effect, or blood
products
in the brain. There are no pathologic extra-axial collections.
The
ventricles and sulci are normal in size and configuration for
age. There are scattered small T2 hyperintensities in the
subcortical, deep, and
periventricular white matter of the cerebral hemispheres, which
are
nonspecific but could be related to minimal chronic small vessel
ischemic
disease in a patient of this age. The major arterial flow voids
appear
unremarkable. The mastoid air cells are opacified bilaterally.
There is mild mucosal thickening in the paranasal sinuses
without evidence of fluid levels.
IMPRESSION:
1. No acute infarction and no evidence of other acute
abnormalities in the
brain.
2. Bilateral mastoid air cell opacification, which could be
related to the
presence of the endotracheal tube. However, clinical correlation
is recommended to exclude the possibility of superimposed
infection.
Brief Hospital Course:
59 year old female admitted for AMS after several months of
declining functional and mental status, partially secondary to
Tramadol overdose. Upon hospitalization, the patient was
intubated for hypoxia, and was found to have an obstructing left
ureteral stone with hydronephrosis and purulent discharge after
placement of perc nephrostomy tube. The patient was also found
to be hypothyroid, with high titers of anti-TPO antibodies and
to have severe cardiomyopathy with EF of [**9-12**]% and a moderately
sized pericardial effusion.
1. Altered mental status: Patient presented with progressive
behavioral changes, daytime somnolence, and agitation. She
admitted to Tramadol and Ativan ingestion although initial tox
screen from urine and blood were negative. Presenting symptoms
were most likely attributable to a combination of tramadol/
other drug abuse, depression, and hypothyroidism, much less
likely an evolving early dementia or degenerative process.
Extensive evaluation for other organic process was unrevealing:
head CT on [**9-19**] negative for acute process, LP on [**9-20**] with
minimal WBCs in CSF (pertinent negatives: gram stain,
enterovirus, West [**Doctor First Name **], Eastern Equine Encephalitis, HSV 1 and 2
negative, crypto Ag, HIV negative), MRI head on [**2115-10-1**]
negative.
Following intubation for hypoxia (see below), the patient
required a significant amount of sedation due to agitation.
Through her course was maintained on Versed, Propofol, Precedex.
Also started on IV Haldol, despite prolonged QTc as an IV
anti-psychotic was felt to be necessary, which was then switched
to PO Seroquel following extubation. Initially following
extubation, the patient was quite delirious on exam and was
unable to recognize even her family members. Mental status
quickly improved although patient showed some persistent
psychomotor retardation. As patient no longer exhibited
agitated behavior, seroquel was stopped and patient was
discharged on no psychiatric medications. Of note, the patient
will need to be followed by a [**Date Range 2447**] for evaluation of
depression once her acute medical issues have resolved.
2. Hypothyroidism: On admission, patient had markedly elevated
TSH and low T3, T4, and fT4. Anti-TPO antibodies were also
markedly elevated. Endocrine was consulted over concern of
Hashimoto's encephalopathy. Patient was initially started on a
low dose of IV thyroxine which was titrated up slowly. Upon
extubation, patient was started on oral thryroxine which was
increased to full replacement based on body weight on [**2115-10-8**]
at 175 mcg. Last thyroid function tests on [**2115-10-4**] were T4 2.6,
T3 40, free T4 0.31. The patient will need repeat T3 and free
T4 on [**2115-10-11**] to ensure that hormone levels are increased
following dose adjustment of levothyroxine. Of note patient
will need repeat TFT in 2 weeks following discharge. Close
follow up with endocrinology has been arranged, especially as
patient has history of cardiomyopathy that would be exacerbated
by any hyperthyroidism.
3. Systolic Congestive Heart failure: Patient observed to have
EF of [**9-12**]% on echo, thought mainly to be due to
hypothyroidism. [**Location (un) **] virus negative and B1 normal. ANCA
negative, [**Doctor First Name **] negative. Improved to 50-55% with thyroxine
therapy. Also with pericardial effusion initially seen on CT.
Initially, in the setting of persistent low grade temps, there
was concern for a purulent effusion, however cardiology did not
feel this likely and a pericardiocentesis was not performed.
Patient will need follow up arranged with cardiology with repeat
echocardiogram
4. Fevers/ Sepsis secondary to obstructive nephrolithiasis and
multifocal pneumonia: Admitted with fever, tachycardia, 2%
bandemia in the setting of a positive urinalysis and altered
mental status. Progressed to respiratory failure requiring
intubation on [**2115-9-19**] and hypotension requiring pressor support
(Dobutamine, Neo, Levo). The patient was initially covered with
Acyclovir, Vanc, Ceftriaxone secondary to concern for
meningoencephalitis, then broadened with Meropenem, Oseltamavir.
CT scan on [**9-19**] showed 1. Multiple bilateral pulmonary
consolidations concerning for multifocal PNA and 2. Obstructing
stone causing L hydroureter and L hydronephrosis.
- For the multifocal pneumonia: The patient was treated with
broad spectrum Abx until [**9-23**]. Patient remained intubated for
almost 2 weeks, but following extubation, her oxygen requirement
resolved rapidly. By the time of transfer out of ICU, she was
saturating well on room air.
- For obstructive nephrolithiasis with left hydronephrosis and
urosepsis: On [**2115-9-20**] got percutaneous nephrostomy tube which
drained pinkish purulent fluid, Cx'd and grew out pansensitive
Klebsiella. The patient was started on a three week course of
fluoroquinolones (initially levofloxacin then ciprofloxacin)
ending on [**10-11**]. Follow up was arranged with urology for
definitive management of nephrolithiasis.
Pertinent negatives: 12 BCx's through MICU course negative.
UCx's other than that described above all negative. Lyme
serology negative, influenza negative, sputum negative, HIV
negative, Legionella in urine negative, blood myco/lytic
negative, mini-BAL for PCP negative, [**Name9 (PRE) **] negative. Also
negative: [**Location (un) **], LCM, Babesia, Leptospira, Ehrlichia,
Adenovirus, Parvo B19 (positive IgG, negative IgM).
LP was performed [**2115-9-20**] with results as above in AMS section.
5. Thrombocytopenia/ Thrombosytosis: Patient presented with
thrombocytopenia likely caused by bone marrow suppression.
Smear without shistos, labs not showing hemolysis, DIC ruled out
(not coagulopathic and with elevated fibrinogen). Mild
splenomegaly on abdominal u/s. Infectious causes of
thrombocyopenia were also negative (HIV, [**Last Name (un) **], HepB, HepC all
negative; CMV and EBV serologies showing past infection).
Platelet counts recovered spontaneously and patient developed a
subsequent thrombocytosis which was thought to be rebound. By
the time of discharge, platelets were 972. Of note, the patient
will require follow up monitoring of platelet count and possibly
further evaluation for essential thrombocytosis.
6. Ileus: While patient was intubated and unresponsive, seen to
have increased TF residuals with constipation. CT scan showed
RUQ focal colonic ileus, treated with decompression and
aggressive BM regimen. Finally started to have some stool
output. Following extubation, ileus resolved.
7. Acute renal failure: Patient was found to be in acute on
chronic renal failure on admission with a creatinine of 1.7
(from presumed baseline of 1.4). Etiology of acute injury
multifactorial with component prerenal ischemia (FeNa 0.13%),
ATN (muddy brown casts), and postrenal L ureter obstruction.
Creatinine peaked at 3.8 but returned to baseline of 1.4 -1.5 by
the time of discharge.
8. Pancreatitis: Was noticed by labs, with elevated lipases but
no CT evidence of pancreatitis. It was thought to be due to the
Propofol that the pt was on and so this was stopped. Following
extubation, patient had no abdominal discomfort and tolerated PO
intake.
9. Transaminitis: U/s with evidence of fatty liver. LFT's were
trended and returned to [**Location 213**] by time of discharge.
10. Anemia: Admitted with Hct 36 which has slowly trended down
over ICU course to nadir of 21 (normocytic), requiring
transfusion with 1U PRBC's on [**10-4**]. No evidence of hemolysis or
active bleed. Serum B12 and folate levels were normal. Iron
studies showing anemia of chronic disease with a reticulocyte
count of 4.1. Because ferritin/TIBC ratio was low, patient was
started on supplementation with ferrous sulfate.
11. Spinal stenosis: Folling extubation, the patient complained
of chronic low back pain due to spinal stenosis. There was no
indication of progression of symptoms and neurologic exam was
not focal (lower extremity strength 5/5, DTR [**11-30**] bilaterally,
urinary incontinence at baseline but intact recatal tone). She
had previously been seen by neurosurgery who recommended
conservative treatment. Maintained on pain regimen of
acetaminophen and lidocaine patches. Opiod analgesics were
avoided in setting of prior abuse.
Medications on Admission:
Ibuprophen prn
Fluoxetine 20 mg daily
Omeprazole 20mg daily
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: end date [**10-11**] (3 week course from
[**9-20**]).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Outpatient Lab Work
please check CBC, serum electrolytes, urinalysis and urine
culture on [**2115-10-14**]
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 PRN () as needed
for pain.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital @ [**Hospital3 **]
Discharge Diagnosis:
Primary Diagnosis:
Altered mental status
Hypothyroidism
Cardiomyopathy
obstructive nephrolithiasis with sepsis; resolved
Secondary Diagnosis:
Depression
Prescription drug abuse
spinal stenosis
Discharge Condition:
stable, Mental status: alert and oriented to person/place/time;
mild psychomotor slowing
Discharge Instructions:
You were admitted with lethargy and decreased consciousness.
You were found to have a very hypoactive thyroid gland, a poorly
functioning heart and a kidney stone obstructing the outflow of
your urine and causing a urinary tract infection. We treated
you with IV antibiotics, thyroid replacement medications, and
placed a tube in your ureter to drain the urine obstructed by
the stone.
Your hospital course was complicated by respiratory failure due
to a bad pneumonia, briefly requiring a breathing tube. You
also suffered acute damage to your kidneys which returned to
[**Location 213**] later in your hospital course. With hormonal
replacement, your thyroid level is returning to normal and your
heart is also recovering.
Although you are still very weak from your prolonged
hospitalization, you are making excellent progress. At time of
discharge, your mental status is improving significantly every
day. It will be important for you to follow up closely with the
endocrinologist, urologist and [**Location 2447**] for further
management of your medical problems (see below for details).
Please make the following changes to your medication regimen:
1. take levothyroxine 175 mcg daily
2. take ciprofloxacin 500 mg every 12 hourse until [**2115-10-11**] for
a total 3 week course following percutaneous nephrostomy tube
placement on [**9-20**]. You will need to take one final dose ofthis
antibiotic following discharge
3. take ferrous sulfate 325mg [**Last Name (un) **] for iron deficiency
4. use lidocaine patch 5% once daily for lower back pain
5. stop prozac: ask your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 2447**]
whether you should start an antidepressant
6. please avoid tramadol and any other opiod- derivative pain
medications such as percocet, lortab, dilaudid, morphine
Please return to the emergency room or call your physician if
you develop worsening confusion, fevers, your nephrostomy tube
no longer drains urine, abdominal pain, nausea/ vomiting, or any
other concerning symptom.
Followup Instructions:
Please make sure to arrange a visit with a [**Last Name (Titles) 2447**] within
1- 2 months.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2115-10-14**] 2:10
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16956**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2115-10-21**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2115-12-13**] 10:00
ICD9 Codes: 0389, 486, 5845, 4254, 2762, 2875, 2724, 311, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4496
} | Medical Text: Admission Date: [**2149-11-19**] Discharge Date: [**2149-11-24**]
Date of Birth: [**2096-1-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ceclor / Dilaudid / Latex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
known aortic valve fibroelastoma
Major Surgical or Invasive Procedure:
excision of aortic valve fibroelastoma
History of Present Illness:
This is a 53 year old nurse who had
bladder suspension surgery [**2149-11-10**] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Postoperatively, she had some chest tightness and a cardiac
workup ensued. An echo was done that revealed a mass on the non-
coronary cusp of the aortic valve that measured approximately
1.3cm and was confirmed by TEE. A stress MIBI was also done at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] which was negative for ischemia. She was afebrile
and serial blood cultures done to r/o endocarditis were
negative,
however she was given prophylactic IV antibiotics.
She was transferred to [**Hospital1 18**] for further cardiac workup. She was
cared for by Dr.[**Doctor Last Name 3733**] who is of the opinion that the mass
is a fibroelastoma, given the location of the tumor and lack of
clinical symptoms of endocarditis. It has been recommended that
this tumor be removed to prevent a thromboembolic event and the
patient has been referred to Dr. [**Last Name (STitle) **] for surgery. As part of
her pre-surgical workup, she has now been referred for cardiac
catheterization. Symptomatically, the patient reports
palpitations. During her hospitalization she was noted to have
ventricular ectopy/trigeminy but did not have any sustained
arrhythmias. She denies any chest pain or dyspnea.
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:
- GERD
- Basal Cell Carcinoma on face s/p excision
- Irritable bowel syndrome
- Stress incontinence s/p bladder sling
- s/p Breast biopsy
- s/p lap chole
Social History:
Works as a nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] hospital. Lives with husband.
-Tobacco history: 20 pack-yr smoking hx, quit 13 yrs ago
-ETOH: occassional wine
-Illicit drugs: none
Family History:
Father died of early MI at 51, mother of [**Name (NI) 5895**] dementia.
No other hx of arrhythmia, cardiomyopathies, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
Pulse:67 Resp: 18 O2 sat: 97%RA
B/P 112/75
Height: 5 feet 3
Weight: 185 lbs
General:A&Ox3, NAD
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]-PVCs noted on tele Murmur [] grade
______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: Left:
Pertinent Results:
ECHO [**2149-11-20**]
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 valve
leaflets (3) appear structurally normal with good leaflet
excursion. A 1.3 x 0.9 cm mass is present on the ventricular
aspect of the noncoronary cusp of the aortic valve. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. The aortic
valve mass is no longer present. There is no aortic stenosis or
regurgitation. Mitral regurgitation is unchanged. The aorta is
intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2149-11-22**] 04:25 10.9 3.34* 9.8* 29.5* 88 29.3 33.1 13.8 158
Source: Line-ij
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2149-11-22**] 04:25 158
Source: Line-ij
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2149-11-20**] 09:27 2561
NOTE NEW REFERENCE RANGE AS OF [**2149-11-18**]
LAB USE ONLY
[**2149-11-22**] 04:25
Source: Line-ij
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2149-11-23**] 04:05 12 0.5 139 4.1 103
CXR [**11-22**]:
FINDINGS: Following removal of left chest drain tubes, there is
no evidence
of pneumothorax. Interval increase in the retrocardiac density
reflects
increased left lower lung atelectasis. Pleural effusion if any,
is minimal on
the left side. Atelectasis is present at the right lung base and
unchanged
since prior study. Right internal jugular line ends at mid/lower
SVC. Status
post AVR with intact sternal sutures. Moderately enlarged heart
size,
mediastinal and hilar contours are stable. There are no discrete
lung
opacities concerning for pneumonia
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2149-11-20**] where the patient underwent removal of
aortic valve mass. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #3 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home in good condition with appropriate follow up
instructions.
Medications on Admission:
AMITRIPTYLINE 10 mg hs PRN:right upper quadrant spasms,
PANTOPRAZOLE 40 daily, ASPIRIN 325 mg daily, DOCUSATE SODIUM 100
mg
daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
2. tramadol 50 mg Tablet Sig: One (1) Tablet 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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for stomach spasm.
Disp:*60 Tablet(s)* Refills:*0*
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. 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:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
GERD, Basal cell cancer on face s/p excision, stress
incontinence s/p bladder sling, s/p breast biopsy, s/p lap
choleycystectomy, appendectomy, c section, Previous problems
with anesthesia: vomitting post anesthesia/dilaudid
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Name (NI) 5572**] office will call with appt
Cardiologist:Dr[**Name (NI) 5572**] office will arrange for you
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 34088**] in [**3-25**] 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:[**2149-11-23**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4497
} | Medical Text: Admission Date: [**2198-6-19**] Discharge Date: [**2198-6-24**]
Date of Birth: [**2120-2-26**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] came to the hospital
on [**6-14**]. A 78-year-old male with a recent positive exercise
tolerance test who was referred in for cardiac
catheterization which revealed 3-vessel coronary artery
disease with an ejection fraction of 35%. He had an occlusive
RCA lesion 100% stenosis, an 80% mid LAD lens, and a 100% OM2
lesion. LVEDP of 17. EF of 34%. A preoperative echocardiogram
also showed a moderately dilated left atrium, a moderately
dilated right atrium, no ASD, mild symmetric LVH, moderately
dilated LV, no AS, 1+ AI, 1+ MR, with impaired relaxation.
Please refer to the official echo report dated [**2198-6-14**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post myocardial infarction at the age of 42.
4. Non-insulin-dependent diabetes mellitus.
5. A former smoker - quit over 30 years ago.
6. Glaucoma.
7. BPH.
SOCIAL HISTORY: He admitted to rate use of alcohol. He is
retired and a very remote smoker (having quit 30 years ago).
MEDICATIONS ON ADMISSION: Glipizide 10 mg p.o. q.a.m. and 15
mg p.o. q.p.m., Zestril 20 mg p.o. once daily, aspirin 325 mg
p.o. once daily, Zetia 10 mg p.o. once daily, Lescol XL 80 mg
p.o. once daily.
ALLERGIES: He is allergic to PENICILLIN (which causes a
rash).
PHYSICAL EXAMINATION ON ADMISSION: He was alert and
oriented. His lungs were clear bilaterally. His heart was
regular in rate and rhythm. His abdomen was benign. His
extremities were warm with no edema or varicosities.
PREOPERATIVE LABORATORY DATA: Sodium of 136, K of 4.3,
chloride of 103, bicarbonate of 25, BUN of 23, creatinine of
1.3, with a blood glucose of 153. White count of 8.6,
hematocrit of 37.5, platelet count of 204,000. PTT of 28.4
with an INR of 1.1. Amylase of 187. Urinalysis was negative.
RADIOLOGIC STUDIES: Preoperative carotid ultrasound showed
40% to 60% plaque on the right internal carotid artery and
less than 40% stenosis of the left internal carotid artery.
A preoperative chest x-ray showed no acute cardiopulmonary
process.
HOSPITAL COURSE: He was referred to Dr. [**Last Name (STitle) 70**] of cardiac
surgery for coronary artery bypass grafting. The patient went
home and came back as a same day admit on the 31st. On the
31st the patient was admitted and underwent coronary artery
bypass grafting x 4 by Dr. [**Last Name (STitle) 70**] with a LIMA to the LAD,
a vein graft to the OM1, a vein graft to OM2, and a vein
graft to the PDA. He was transferred to the cardiothoracic
ICU; A-paced, in stable condition, on an epinephrine drip at
0.03 mcg/kg per minute and a propofol drip and 30 mcg/kg per
minute. He was seen by cardiology in the immediate
postoperative period for Wenckebach periodically alternating
with a sinus rhythm at 75. He remained intubated and sedated
at the time of exam. On EKG he had first-degree AV block, on
epinephrine and Neo-Synephrine. Postoperative labs showed a
white count of 15.6, a hematocrit of 29.4, a platelet count
of 166, and creatinine stable at 1.1. In the immediate
postoperative period his pacing wires did not capture, and
the EP service placed a temporary pacing wire for his AV
block via the right femoral vein.
On postoperative day 1, he was V-paced with a blood pressure
of 112/39, on epinephrine at 0.03 and Neo-Synephrine at 0.3.
He remained intubated with his paced rhythm. His incisions
were clean, dry, and intact. His abdomen was soft and
nontender with trace peripheral edema. His central venous
line and pacing epicardial wires did remain in place, and the
wean of his pressor began. Dr. [**Last Name (STitle) **] requested that the
patient be kept intubated overnight on the first night and
was extubated on the morning on postoperative day 2 on 40%
FiO2 face mask, in first-degree AV block, also on an insulin
drip at 2 units per hour. His white count remained stable at
16 with a hematocrit of 29.2. He was in no apparent distress,
and he continued with Lasix diuresis. He was started back on
his oral diabetic medications. He was alert and oriented. In
no apparent distress. His exam was otherwise unremarkable. He
was switched over to p.o. Lasix and was transferred out to
the floor. He got out of bed and seen and evaluated by PT,
and his temporary epicardial pacing wires were removed. He
was also seen by case management.
On postoperative day 4, the patient was doing very well. He
was ambulating. He was switched over to p.o. Percocet for
pain management. The patient was ambulating well and was
waiting to do stairs prior to his discharge. He did a level 4
on postoperative day 4. His creatinine rose slightly to 1.4.
He was also restarted on his anti-cholesterol [**Doctor Last Name 360**]. His
central venous line was removed. He was in a sinus rhythm at
74 with a blood pressure of 140/62. His temporary pacing wire
was removed, and he remained also with a first-degree AV
block.
On postoperative day 5, the date of discharge, he was alert
and oriented. His exam was unremarkable. His sternum was
stable. He was to clear a physical therapy level 5, and was
seen by Dr. [**Last Name (STitle) **] and deemed ready for discharge on
postoperative day 5, and he was discharged to home with VNA
services with the following discharge instructions.
DISCHARGE INSTRUCTIONS: He was instructed to call his
primary care physician (Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]) and schedule a
follow-up appointment post discharge in the next 2 weeks as
well as calling Dr.[**Name (NI) 5572**] office for an appointment to
see him for his postoperative surgical visit 4 weeks post
discharge.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 4.
2. Hypertension.
3. Hypercholesterolemia.
4. Status post myocardial infarction.
5. Non-insulin-dependent diabetes mellitus.
6. Glaucoma.
7. Benign prostatic hyperplasia.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day (for 10 days).
2. Potassium chloride 20 mEq p.o. twice a day (for 10 days).
3. Colace 100 mg p.o. twice a day.
4. Enteric coated aspirin 81 mg p.o. once a day.
5. Glipizide 10 mg p.o. once a day in the morning.
6. Glipizide 15 mg p.o. once a day in the evening.
7. Protonix 40 mg enteric coated p.o. once a day.
8. Zetia 10 mg p.o. once a day.
9. Lipitor 40 mg p.o. once a day.
10. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. as needed
(for pain).
11. Hydralazine hydrochloride 20 mEq p.o. q.6h.
DISCHARGE DISPOSITION: The patient was discharged to home
with VNA services on [**2198-6-24**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-6-25**] 10:33:16
T: [**2198-6-25**] 12:44:19
Job#: [**Job Number 61955**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4498
} | Medical Text: Admission Date: [**2181-9-15**] Discharge Date: [**2181-9-16**]
Date of Birth: [**2181-9-15**] Sex: M
Service: NEONATOLOGY
!!! This is an interim summary. Please see addendum. !!!
HISTORY OF PRESENT ILLNESS: The patient is the 2.78 kg
product of a 34-week gestation both to a 27-year-old
gravida 4, para 2 woman, who was admitted to the [**Hospital1 18**] on the
right-sided abdominal pain of unclear etiology. Her
evaluation included surgical consultation and abdominal CT,
raising the question of appendicitis. No surgical diagnosis
was found. Question of chorio was raised because of new
onset oligo. There was no fever, however. There were no
other risks for sepsis noted. The mother received
antibiotics approximately 12 hours prior to delivery.
antigen, rubella immune, RPR nonreactive, maternal blood type
A+ with a negative antibody status.
Labor was induced due to oligo and pain. SVD occurred this
morning. The patient did well in the DR [**Last Name (STitle) 151**] [**Name (STitle) **] of 8 and
9. He was brought back to the NICU after visiting with his
parents. Upon admission exam, he was noted to have an
anterior anus which is not patent. There was no evidence of
fistula. Physical exam on admission showed a pink, active,
nondysmorphic infant. HEENT was normal. The nares appear
patent bilaterally. The palate was intact. The neck was
without lesions. There were no skin lesions. Eyes were with
bilateral red reflexes and normal irises. The cardiac exam
showed a normal S1 and S2 without murmurs. Abdomen was
benign. It was soft and nondistended. The genitalia showed
normal preterm male. Testes were distended bilaterally.
Hips were normal. The spine was intact. Neuro exam was
nonfocal and age-appropriate.
HOSPITAL COURSE BY SYSTEMS:
Cardiovascular-respiratory: The patient remained 100%
saturated on room air throughout his hospital stay. There
was no murmur of congenital heart disease. BP has been good
range.
Fluids-Electrolytes-Nutrition: The patient was maintained
NPO on admission. I.V. D10/W at 80 cc per kg was begun.
GI: The patient was made NPO and a had a tube placed to low
intermittent suction. The abdomen was nondistended.
Hematologic: CBC and diff are pending at the time of this
dictation. The patient has not received any blood products.
Infectious Disease: The patient is begun on ampicillin and
gentamicin for a 48-hour rule out sepsis. Blood culture has
been sent to the bacteriology laboratory at [**Hospital1 **].
Neurologic: The patient has manifested a normal neurologic
exam throughout his hospital stay.
Routine Healthcare Maintenance: Screening specimen has been
set to the [**Location (un) 511**] Regional Newborn Screening Program.
Due to the early timing of this screen, it should be repeated
again prior to ultimate discharge summary.
The patient has not received hepatitis B vaccine during the
hospital.
The patient has received Ilotycin ophthalmic prophylaxis and
vitamin K. A hearing screen has not been done during this
hospitalization and should be done before ultimate discharge
home.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**],
7-North NICU, care of pediatric surgical team.
DISCHARGE DIAGNOSES:
1) 34-week premature infant.
2) Rule out sepsis.
3) Imperforate anus.
!!! This is an interim summary. Please see addendum. !!!
DR.[**Last Name (STitle) 37692**],[**First Name3 (LF) 37693**] 50-454
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2181-9-15**] 09:24
T: [**2181-9-15**] 09:35
JOB#: [**Job Number 44817**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4499
} | Medical Text: Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-19**]
Date of Birth: [**2146-6-16**] Sex: F
Service: NB
Date of admission to NICU was [**2146-6-17**] and day of
discharge was [**2146-6-19**] to newborn nursery.
HISTORY OF PRESENT ILLNESS: The infant was admitted for
sepsis evaluation. During the evaluation, 1 episode of
desaturation was noted and the infant was placed on nasal
cannula. The infant is a full term, 4435 gram female newborn
who was born to a 19-year-old, gravida 1, para 0 now 1
mother. Prenatal screens: O+, antibody negative, hepatitis
B negative, RPR nonreactive, rubella immune, GBS positive,
HIV negative. Pregnancy reported benign. Sepsis risk
factors reviewed. Mother is GBS positive. Maternal T-max of
102.8. Ruptured membranes x9 hours with clear fluid.
Intrapartum antibiotics greater than 4 hours prior to
delivery and fetal tachycardia. Maternal anesthesia by
epidural. Delivered by cesarean section for nonreassuring
fetal heart rate tracing. Required positive pressure
ventilation at delivery. Apgars 3 and 7.
PHYSICAL EXAMINATION AT DISCHARGE: Current weight 4330
grams, greater than 90th percentile, length 53 cm, greater
than 90th percentile, and head circumference 36 cm, greater
than 90th percentile. Vital signs per Careview. LGA female
infant. Respiratory: The infant remains on room air.
Breath sounds are equal and clear. No retractions.
Respiratory rate are 30 to 60. Cardiac: No audible murmur
on exam, regular rate and rhythm. Pulses are palpable and
equal. Capillary refill less than 3 seconds. Mucous
membranes are pink and moist. Skin is intact, no lesions,
rashes or bruises on exam. Mongolian spot on buttocks. GI:
Abdomen soft and round, positive bowel sounds, no
hepatosplenomegaly on exam. No palpable masses on exam.
Patent anus. GU: Normal female genitalia. Neuro: Anterior
fontanels open and soft. Infant alert, awake and active,
good tone. No sacral dimple on exam.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant
initially placed on nasal cannula O2 at 200 cc with an FIO2
of 50% on admission. In NICU, weaned to room air on day of
life #2. The infant currently remains on room air.
Cardiovascular: No concerns at this time. No murmur at this
time.
Fluid and electrolytes nutrition: The infant initially fed
in L&D for a D stick of 34. Infant made NPO upon admission
to NICU. Total fluids were at 60 per kilo per day of D10W
with daily D sticks. Follow intraoral feeds ad lib with
Similac 20 cal on day of life #1.
GI: No clinical signs of jaundice. Bilirubin on day of life
#3 was 5.6/0.4. The infant does not require phototherapy at
this time.
Hematology: Blood type not identified. Current hematocrit
on admission was 61.6 with a platelet count of 145,000.
Repeat on day of life #2, hematocrit 58 with a platelet count
of 130,000. Repeat platelet count on day of life # 142.
ID: Blood culture with CBC with differential on admission to
the NICU results: White count 11.3, 52 polys, 3 bands with
362 nucleated red blood cells. Repeat CBC on day following
life #2 results: WBC 15.3, 57 polys, 0 bands and 85
nucleated red blood cells. Lumbar puncture performed on
admission due to clinical status for sepsis, results normal.
CSF culture negative to date. Blood culture is also negative
to date. The infant will be treated with ampicillin and
gentamicin for a total of 7 days for presumed sepsis.
Gentamicin levels done on day of life #3: Gentamycin trough
was 1.4 and gentamycin peak is pending.
Neurologic: The infant does not meet criteria for head
ultrasound. Recommend hearing screen prior to discharge.
CONDITION ON TRANSFER TO NEWBORN NURSERY: Stable.
DISCHARGE DISPOSITION: To newborn nursery. Name of
pediatrician not yet identified.
CARE AND RECOMMENDATIONS: Feeds: Similac 20 calories ad
lib. Medication: Gentamicin 18 mg q.24 h., Ampicillin 500
mg IV q.12 h. for a total of 7 days.
NEWBORN SCREENING SENT PER PROTOCOL: Results are pending.
DR [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **] 50.AEF
Dictated By:[**Last Name (NamePattern1) 73117**]
MEDQUIST36
D: [**2146-6-19**] 02:30:14
T: [**2146-6-20**] 08:12:17
Job#: [**Job Number 73118**]
ICD9 Codes: V053, V290 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.