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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4500
} | Medical Text: Admission Date: [**2158-11-14**] Discharge Date: [**2158-12-7**]
Date of Birth: [**2091-4-21**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old man
who came to the [**Hospital1 69**] on the
[**4-14**] for cardiac catheterization. During that
catheterization, he was found to have a patent LIMA, LAD and
SBG times two and patent stents. After catheterization, further
patient had history of hematuria and pneumaturia with a
possible anastomosis between his GI and urinary system. He
had seen a doctor on the [**3-26**] for this problem and
his INR was found to be 4 so his Coumadin was held, however
the next day he noted some red urine with clots. Over the
week prior to admission, he had complaints of pain with
urination and bloody urination.
On the 28th, the day prior to admission, the patient noted
air in his urine and also flecks of darker material and pus
or white material in the urine. The patient denied any fever
or chills. Had not had any changes in his bowel movements.
He has no history of urinary tract infections. He does have
a history of positive renal stones and has had ureteral
stents placed 10 years prior to admission. The patient had
some nausea, but no vomiting prior to admission.
PHYSICAL EXAMINATION: On admission blood pressure in the 100
to 110 range over 60s. Temperature 98.3 F, heart rate 76 and
respiratory rate of 20. In general the patient was alert and
oriented times three in no apparent distress. Head, eyes,
ears, nose and throat: The patient had pupils that were
equal, round and reactive bilaterally. Extraocular motions
were intact. Chest: He had a few rales at the left
base, no rhonchi, no wheezing. Decent air exchange.
Cardiovascular system: He had distant heart sounds, slight
murmur, no gallops, no rubs. Abdomen was soft, not
distended. He had some mild suprapubic tenderness. Normal rectal
tone, no gross blood, nontender prostate, stage I sacral ulcer,
no groin cellulitis. Extremities: He had lower extremity
muscle wasting, no cyanosis, clubbing or edema. Legs were
warm. In the left distal pulses were not palpable. Skin was
warm and dry. He had moist mucous membranes.
PAST MEDICAL HISTORY:
1. The patient has end stage renal disease. He is on
hemodialysis on Monday, Wednesday and Fridays.
2. He had coronary artery bypass surgery in [**2151**].
3. He also has a history of five myocardial infarctions.
4. He had cardiac catheterization in [**2158-4-17**] with
stent placement.
5. He has a history of congestive heart failure with an
ejection fraction listed between 15 and 25%.
6. History of hypertension.
7. Patient has diabetes type 2 requiring insulin for
control.
8. He has peripheral vascular disease status post
aortobifemoral bypass.
9. Patient has a history of atrial fibrillation and flutter
with an episode of ventricular tachycardia in [**2158-3-17**]
for which he had electrophysiology treatment with ablation
and a defibrillator pacer placed.
10. Hypercholesterolemia.
11. Diverticulitis.
12. Splenectomy.
13. Ventral hernia repair times four.
14. Tonsillectomy and adenectomy.
15. Left leg internal fixation.
16. Peripheral sensory neuropathy.
MEDICATIONS ON ADMISSION:
1. Toprol.
2. Imdur.
3. Digoxin.
4. Neurontin.
5. NPH insulin.
6. Humalog insulin.
7. Nephrocaps.
8. Coumadin.
9. Coreg.
10. Lisinopril.
11. Phos-Lo.
12. Zantac.
13. Dulcolax.
ALLERGIES:
1. Amiodarone.
2. Tetracycline.
3. Seldane
4. Procainamide.
5. Shellfish.
6. Steri-Strips.
LABORATORIES ON ADMISSION: The patient had a white count of
15 with 71 polys, no bands, hematocrit of 40. His Chem-7 was
essentially normal. His urine showed gross infection with
greater than 1,000 white blood cells, large blood, many
bacteria.
HOSPITAL COURSE: The patient was admitted to the hospital
and started on antibiotic treatment for his urinary tract
infection which was suspected to be entero vesicular fistula
given his history of diverticulitis. Urology was consulted.
A CT Scan just after admission showed sigmoid diverticulitis
with sigmoid vesicular fistulas. The patient was started on
Levaquin, Flagyl and Ampicillin. Due to the extremely long
hospitalization and transfer to the Surgical Service and then
back to the Medical Service, the rest of the dictation
summary will be by system to give a concise review of
hospital occurrences.
1. GI / GU SYSTEMS: As mentioned in the HPI, the patient
was admitted with a enterovesical fistula and started on
triple antibiotic coverage. The patient was seen by the
Urology Department and Surgical Colorectal Surgery Department
as well as by Infectious Disease. Initially, it was deemed
more appropriate to treat the patient with medial therapy
i.e. triple antibiotic coverage to decrease inflammation in
the colon and bladder area. He had a Foley catheter placed
which on several occasions was clogged and had to be
readjusted.
Following medical treatment, the patient was transferred to
the Surgical Service on [**11-23**] where he underwent a
diverting colostomy with Hartmann pouch of the distal segment
and his bladder was oversewn. A suprapubic catheter was
placed. Due to the contaminated nature of the surgery and
the fact that the patient had an abscess within his abdominal
cavity as shown on CT Scan, only his fascia was closed and
the skin and subcuticular layer were left open to heel by
secondary intention. Please refer to the [**11-23**]
operative note by Dr. [**Last Name (STitle) 1888**] for full details of the surgery.
Following surgery, the patient underwent a complicated
medical course with a prolong stay in the SICU and eventual
transfer to the floor. It should be noted that the patient's
preoperative mortality morbidity was estimated to be 50% due to
his
complicating medical conditions.
As the patient improved, he was transferred back to the
Medical Service on [**11-30**] for fine tuning of his
urine, endocrine and cardiac systems. He was maintained on
triple coverage antibiotics of Flagyl, Levaquin and
Vancomycin until [**12-6**] when there were no further
signs of infection and patient was doing well clinically. It
should be noted that postoperatively, the patient had some
hypotension and there was fear of sepsis so he was pan
cultured and aggressive antibiotic treatment continued,
however all of the cultures with exception of urine culture
returned as negative.
On [**12-6**], the patient had an abdominal CT Scan which
showed no abscess within the abdominal cavity and only the
open abdominal wound left from surgery. The patient will
have the suprapubic catheter in place until follow up with
Dr. [**Last Name (STitle) 1888**]. He gradually developed stools through his ostomy
and good gas flow.
2. CARDIOVASCULAR: As mentioned before, the patient has
extensive cardiac disease. While in the hospital, he was
monitored on Telemetry which showed no significant events.
His pacer defibrillator was interrogated after surgery and
was found to be in normal working order. He was kept on
Carvedilol for blood pressure and cardiac status. His
aspirin was restarted during hospital stay after surgery and
Coumadin was restarted for the patient's atrial fibrillation.
During the time of surgery and during the postoperative
period, the patient was anticoagulated with heparin.
3. PULMONARY: The patient has an extensive tobacco history.
During his hospitalization his pulse oximetry saturations
were within normal limits. There was some mild congestive
heart failure clinically on x-rays due to his fluid status,
but this was corrected with dialysis. It should also be the
patient had a methicillin-resistant Staphylococcus aureus
positive nasal swab for which he was placed on isolation.
4. RENAL: As mentioned, the patient has end stage renal
disease and he receives tri-weekly hemodialysis. In the GI /
GU section the patient's enterovesical fistula was discussed.
During the week of [**11-26**], the patient's fluid status
was deemed to be that he was retaining quite a bit of fluid.
He underwent daily dialysis for several days during which 2
to 3 kilograms were taken off per day. This gradually
improved the patient's fluid status back to his baseline and
a more appropriate dry weight.
The patient's antibiotics were renally dosed while in
hospital. The patient was also noted to have reasonable
urinary output from his suprapubic catheter after surgery and
no signs of obstruction of this portal. The suprapubic
catheter will be kept in place until follow up with Dr.
[**Last Name (STitle) 1888**] to serve as a pressure outlet in order to not distend
the bladder which had recently been oversewn.
5. INFECTIOUS DISEASE: As mentioned previously, the patient
was found to have a methicillin-resistant Staphylococcus
aureus positive nasal swab. He is also status post
splenectomy. Some hypotension in the SICU after surgery led
to a concern for sepsis as well as a high white blood count
that maxed at 19. The patient was maintained on triple
antibiotic coverage including Flagyl, Levaquin and
Vancomycin. He was pan cultured. The cultures were found to
have no growth with the exception of the urine culture. All
of his antibiotics were dosed at renal levels. Antibiotics
were stopped on the [**12-5**] as the patient had been
afebrile, white count returning to baseline and clinically
improving and a sufficient course of antibiotics had been
met.
6. ENDOCRINE: The patient had been admitted on NPH insulin
and Humalog sliding scale. The consultation with the Josalin
diabetic doctors recommended changing the patient to a longer
acting Lantus insulin for once a day basal coverage and
maintaining the Humalog sliding scale. After surgery, the
patient was switched back to his Lantus insulin at a lower
dose and gradually increased to 40 units q.h.s. and
maintained on Humalog sliding scale for meals and coverage
throughout the day. The patient checks his own blood sugars
and is quite familiar with his insulin regimen and its
management.
7. HEMATOLOGY: The patient has received Epogen for
hemopoietic stimulus. His hematocrits remained stable,
although relatively low probably due to chronic
myelosuppression.
8. NEUROLOGY: The patient has a peripheral neuropathy. He
also noted that he had numbness in his left 3rd through 5th
digits which is chronic for him. After his operation, the
patient was noted to have some postoperative hallucinations
which were believed to be secondary to his epidural catheter
and anesthesia. He gradually cleared from these and returned
to [**Location 213**] mental status.
9. MUSCULOSKELETAL: The patient noted that he occasionally
gets weakness and numbness in his left arm where is AV
fistula is following hemodialysis, but this gradually
improves within hours. It should also be noted that on the
[**12-6**] when the patient was undergoing Physical
Therapy and sitting up in a chair with a strapper on his
chest, he noted to start to have left chest wall pain
associated with palpation of his midthoracic ribs on the
left, breathing and movement. A chest x-ray was taken on the
[**12-7**] to rule out rib fracture.
10. DERMATOLOGY: The patient had some bilateral heel
blisters when he was transferred back to Medicine and
undergoing large volume hemodialysis. He was gradually
improved with preventative measures such as air mattress and
soft cushioning under the heels. The patient was also
instructed on how to work with his ostomy bag by the ostomy
nurse. In terms of his abdominal surgical wound, the patient
was instructed on the wet to dry packing and t.i.d. dressing
changes. To watch for signs of infection such as erythema or
discharge.
DISPOSITION: The patient will be discharged to rehab because
of his decreased physical conditioning. It should be noted that
at home, he was not quite very mobile and used a motorized
wheelchair. However, when Physical Therapy worked with him
at the end of his hospitalization, the patient had trouble
standing and pivoting. It was agreed that some rehab would
be beneficial to him.
The patient was also set up with a new internist at the [**Hospital1 1444**] by the name of Dr. [**First Name (STitle) **]
[**Name (STitle) 24596**]. He will see this doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**12-19**] at
3:30 PM in the [**Last Name (un) 469**] building.
DISCHARGE DIAGNOSES:
1. Enterovesical fistula status post diverting colostomy and
Hartmann pouch with bladder oversewn.
2. End stage renal disease on hemodialysis.
3. Coronary artery disease status post coronary artery
bypass graft and MIs.
4. Congestive heart failure with low ejection fraction.
5. Diabetes mellitus type 2 on insulin.
6. Hypertension.
7. Peripheral vascular disease.
8. Atrial fibrillation flutter status post pacer
defibrillator.
9. Hypercholesterolemia.
10. Diverticulitis.
11. Splenectomy.
12. Ventral hernias.
13. Peripheral sensory neuropathy.
DISCHARGE MEDICATIONS:
1. Carvedilol 3.125 mg p.o. b.i.d., hold for systolic
pressure less than 90 or heart rate less than 60.
2. Calcium Acetate two tablets p.o. q. AC.
3. Fentanyl patch 50 mcg per hour, apply every 72 hours.
4. Lantus or Glargine insulin 40 units q.h.s.
5. Sliding scale Humalog insulin per patient dosing.
6. Protonix 40 mg a day.
7. Warfarin 5 mg a day.
8. Neurontin 200 mg twice a day.
9. Percocet one to two tabs every four to six hours p.r.n.
pain.
10. Dulcolax suppositories as needed.
Please note the patient is to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 24596**]
as mentioned above. He is to follow up with Dr. [**Last Name (STitle) 1888**] of
the Surgery Department within two weeks of discharge. He is
to call for an appointment for that at which time his
surgical wounds and suprapubic tube will be addressed. If
there are any concerns prior to that, he should call Dr.[**Name (NI) 25573**] office.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**]
Dictated By:[**Last Name (NamePattern1) 2215**]
MEDQUIST36
D: [**2158-12-7**] 15:43
T: [**2158-12-7**] 16:44
JOB#: [**Job Number 25574**]
cc:[**Name8 (MD) 25575**]
ICD9 Codes: 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4501
} | Medical Text: Admission Date: [**2115-10-5**] Discharge Date: [**2115-10-9**]
Date of Birth: [**2066-9-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Loss of Consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 49 yo M w/ h/o DVT x2 and hypertension who was
transferred from [**Hospital3 1280**] for bilateral PE with hemodynamic
instability.
.
Patient was walking upstair on AM of admission when he suddenly
syncopized. He was witnessed to fall to the ground after walking
up a flight of stairs and was unconscious and unresponsive for
approximately 2 to 3 minutes. He did not have any seizure
activity. He then woke up confused and diaphoretic. He denies
chest pain/SOB at that time. He was sent to [**Hospital1 **]. He was
hypoxic at 91% on RA and has BP of 80 over palp. Blood pressure
had been fluid responsive. CT chest revealed multiple large
bilateral PE (large proximal right mainstem thrombus and distal
left main thrombus, paucity of vessels R>L). Heparin was then
started. EKG showed S1Q3T3. HE also became hypotensive and was
transferred to [**Hospital1 18**] for possible thrombolysis. His initial VS
were T 96.3 P 79 BP 133/102 93% on RA.
.
According to him, he had right DVT 2 years ago in the setting of
multiple baseball injury to the same place. He could not recall
what medication he was on or how long he was on it. He again
have another DVT, this time on the left side discovered on
[**2115-9-7**] on the day that he was suppose to go for Archilles
tendon surgery. He went for the surgery and was on lovenox for 2
weeks after that (qd dosed). Reports a brother who "is
anticoagulated because he clots." Female members of his family
has no history of spontaneous abortion.
.
Patient has no h/o spontaneous bleeding. He was guiaic negative
in the ED. He claims that he did not hit his head when he fell.
.
Currently he has no chest pain or shortness of breath.
Past Medical History:
HTN
DVT
Achilles tendon repair [**2115-9-3**]
Social History:
patient denies smoking or alcohol. Married with children, plays
baseball
Family History:
+ brother with ? of hypercoag. d/o
Physical Exam:
Gen- [**Last Name (un) **] with family at bedside; breathing comfortable on
RA. NAD
HEENT- PERRLA, EOMI
CV- RR, no r/m/g, Hyperdynamic with PMI at sternal boarder. no
overt sternal heave.
resp- CTA B
abdomen- NT/ND, NABS. Guaiac "already 2 times". Neg per Med
Record
ext- no c/c/e. slight calf tenderness in his right LE, with
surgical scar, c/d/i. 2+ DP/PT
Pertinent Results:
Admission Labs:
.
[**2115-10-5**] 07:00PM CK(CPK)-219*
[**2115-10-5**] 11:00AM CK(CPK)-242*
[**2115-10-5**] 04:35AM CK(CPK)-48
[**2115-10-5**] 02:30AM CK(CPK)-204*
.
[**2115-10-5**] 07:00PM CK-MB-3 cTropnT-0.05*
[**2115-10-5**] 11:00AM CK-MB-4 cTropnT-0.10*
[**2115-10-5**] 04:35AM CK-MB-NotDone cTropnT-0.14*
[**2115-10-5**] 02:30AM CK-MB-3 cTropnT-0.14*
.
[**2115-10-5**] 02:30AM WBC-8.9 RBC-4.78 HGB-14.0 HCT-41.3 MCV-86
MCH-29.4 MCHC-34.0 RDW-13.3
[**2115-10-5**] 02:30AM NEUTS-83.3* LYMPHS-13.0* MONOS-2.3 EOS-1.2
BASOS-0.1
[**2115-10-5**] 02:30AM PLT COUNT-176
[**2115-10-5**] 02:30AM GLUCOSE-139* UREA N-20 CREAT-1.2 SODIUM-142
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2115-10-5**] 04:35AM PT-13.3 PTT-88.1* INR(PT)-1.2
[**2115-10-5**] 04:35AM CALCIUM-7.0* PHOSPHATE-2.7 MAGNESIUM-1.7
Discharge Labs:
[**2115-10-9**] 05:22AM BLOOD WBC-5.2 RBC-5.10 Hgb-15.1 Hct-42.8 MCV-84
MCH-29.6 MCHC-35.4* RDW-13.2 Plt Ct-206
[**2115-10-9**] 12:50PM BLOOD PT-17.6* PTT-47.5* INR(PT)-2.0
[**2115-10-9**] 05:22AM BLOOD Glucose-96 UreaN-17 Creat-1.3* Na-140
K-4.2 Cl-104 HCO3-24 AnGap-16
[**2115-10-9**] 05:22AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.0
Imaging:
ECHO [**2115-10-7**]:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. Trace aortic regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Trivial
mitral
regurgitation present.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
Brief Hospital Course:
Impression and plan:
49yo man with a history of 2 previous DVTs presented with
hemodynamically unstable bilateral pulmonary embolism,
transfered to [**Hospital1 18**] for possible tPA.
.
1.) Bilateral PE: Pt was initially tranferred to [**Hospital3 **]
Hospital for ?tPA administration as was hemodynamically unstable
at previous hospital. On presentation, the patient was volume
rescusitated and never became hemodynamically unstable -
therefore tPA was not administered. Pt was started on heparin
drip to achieve therapeutic PTT of 60-100. Throughout hospital
course, the heparin drip ranged from 1000-1300units/hr. Patient
was also started on Coumadin at 5mg PO qhs to goal INR [**3-14**].
Patient was discharge with INR = 2.0 with plans to continue
current Coumadin dose (5mg qhs) and will get 1 dose Lovenox 80mg
SC tonight, with plans to follow up in his [**Hospital 6435**] clinic on [**10-11**]
to recheck INR and adjust Coumadin dose as needed. It is likely
that he will need anticoagulation for at least 1 year given that
this episode was in setting of trauma (clot was present prior to
OR for achilles repair; likely [**3-13**] trauma from the baseball), if
not life-long anticoagulation given that patient developed DVT
under the circumstances. Our final recommendation to him was
for life long anticoagulation. He will follow up with hematology
(Dr. [**Last Name (STitle) **] for re-check of hypercoaguable labs in a couple
months, again given the fact that the patient developed this
clot and ?family history of a brother with some clotting
disorder.
.
2.) Hypertension: Hypertension meds held during hospitalization
as presented with ?hemodynamic instability. Pt advised to
restart all outpatient medications on discharge. .
Medications on Admission:
Wiaspan 500
Doxazosin 2mg
Ficardura
Ecotrin
Foltx
Discharge Medications:
1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
2 x 2mg tablets with 1 x 1mg tablets every night (dose may
change after blood levels drawn on friday [**10-10**] - will be
instructed at that time).
Disp:*30 Tablet(s)* Refills:*2*
2. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Take
2 x 2mg tablets with 1 x 1mg tablets every night (dose may
change after blood levels drawn on friday [**10-10**] - will be
instructed at that time).
Disp:*60 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please draw coags (PT, PTT, INR) on [**10-10**].
Adjust Coumadin as needed for goal INR of [**3-14**].
Follow up coag lab draws as needed after [**10-10**].
4. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once tonight ([**10-9**]) for 1 doses.
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Pulmonary Embolism
2.) Deep vein thrombosis in gastrocnemus vein
Discharge Condition:
Good
Discharge Instructions:
1.) Please contact physician if experience shortness of breath,
chest pain or pressure, increased swelling in leg, fainting,
fever > 100.4, any other questions/concerns
2.) Please follow up with appointments as directed below
3.) Please take medications as directed. [**Month (only) 116**] restart all
outpatient medications.
4.) Please follow diet as directed (eat consistent amounts of
green, leafy vegetables as described - do not have to avoid
them)
Followup Instructions:
1.) Please follow up at Dr.[**Name (NI) 62797**] clinic on Friday [**2115-10-11**] for
lab draws (may show up to clinic anytime friday morning). At
that time, dose of coumadin may be adjusted and will need to
follow up in clinic as directed.
2.) Please make an appointment with Dr. [**Last Name (STitle) **] (hematologist) in
a couple months time in order to re-check the hypercoaguable
work up that was checked previously. This will help with future
management in terms of if need to be on life-long coumadin or if
only need to be on coumadin for approximately 1 year.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4502
} | Medical Text: Admission Date: [**2102-8-7**] Discharge Date: [**2102-8-12**]
Date of Birth: [**2044-12-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Atrial fibrillation
Major Surgical or Invasive Procedure:
[**2102-8-9**] - Bilateral mini thoracotomy with pulmonary vein
isolation using the [**Company 1543**] Gemini-x system with resection of
left atrial appendage.
History of Present Illness:
57-year-old female who is status post atrial flutter ablation
who now has
recurrent atrial fibrillation despite taken Sotalol 80 mg b.i.d.
Of note, earlier this year, she had a cardiac catheterization
and was found to have one vessel coronary artery disease in her
RCA and drug eluting stent was diploid. She was doing well up
until several weeks ago when she again began to experience
palpitations and was found to be in atrial fibrillation.
Specifically, of note, the cardiac catheterization on [**2101-7-20**] at [**Hospital 9464**] Hospital revealed RCA lesion of 90%, drug
eluting stent was deployed that reduced to 0% after stent
deployment. A cardiac echocardiogram at this time also revealed
an EF of 60%, mild MR, and trace TR.
Past Medical History:
CAD status post RCA stent, sleep apnea, intermittent atrial
arrhythmias which include atrial flutter and atrial
fibrillation. She is status atrial flutter ablation, diabetes,
hypertension, hypercholesterolemia, and depression.
Her past surgical history is noted for appendectomy,
tonsillectomy, removal of lesion, breast reduction, and right
shoulder surgery.
Social History:
Occupation, she is currently on disability. Her last dental
examination was within the last year. She states she has a
remote tobacco history and quit approximately 25 years ago. She
denies any alcohol use in the past few years (used to have
cocktails regularly)and currently lives with her husband.
Family History:
Family History: (parents/children/siblings CAD < 55 y/o):Her
family history is noted for her father who died from MI at the
age of 57.Her mother died at the age of 60, history of stroke.
Physical Exam:
Pulse:70 Resp:20 O2 sat: 98%
B/P Right: 110/60 Left:
Height: 5'3" Weight:230LB
General:A&O x3
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**2102-8-9**] ECHO
The left atrium is markedly dilated. The left atrium is
elongated. 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. 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. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. After left atrial appendage resection, there does no
significant remnant is visible. Dr. [**Last Name (STitle) 914**] was notified in
person of the results in the operating room at the time of the
study.
[**2102-8-7**] CTA
1) Stent at the RCA is patent with a possibility of mixed plaque
distally to the stent. Extensive atherosclerotic disease at the
LAD and left circumflex with indeterminate significance.
2) Left common orifice of pulmonary veins. Two right pulmonary
veins. 3)
Calcified lymph nodes at the upper abdomen and a number of
granulomas in liver and spleen - consistent with previous
granulomatous disease or sarcoidosis.
[**2102-8-12**] 05:22AM BLOOD WBC-10.6 RBC-3.21* Hgb-9.0* Hct-28.6*
MCV-89 MCH-27.9 MCHC-31.3 RDW-13.9 Plt Ct-203
[**2102-8-12**] 05:22AM BLOOD Glucose-113* UreaN-27* Creat-0.8 Na-137
K-4.5 Cl-105 HCO3-26 AnGap-11
Brief Hospital Course:
Mrs. [**Known lastname 13712**] was admitted to the [**Hospital1 18**] on [**2102-8-7**] for surgical
MAZE procedure. She was placed on heparin as she had been off
her coumadin for several days. A CTA was obtained
preoperatively. On [**2102-8-9**], she was taken to the operating room
where she underwent a mini maze procedure. Please see separate
dictated operative note for details. Postoperatively she was
taken to the intensive care unit for monitoring. She later awoke
neurologically intact and was extubated. She was transferred to
the floor for further recovery. Chest tubes were discontinued
without complication. Plavix was resumed for coronary stent.
Coumadin was resumed for chronic atrial fibrillation.
Colchicine and NSAIDS were initiated per Dr. [**Last Name (STitle) 914**]. Sotalol
was resumed and the patient remained in sinus rhythm until
discharge. She was gently diuresed. Physical therapy was
consulted for post-op strength and mobility. She was cleared
for discharge to home on POD 3.
Medications on Admission:
Aspirin 81(1), Lipitor(40), Sotalol 80(2), Plavix 75(1)-LD [**8-2**],
Coumadin-dose varies-LD [**8-3**], Lasix 40 mg prn based on leg
edema, Actos 45(1), Zoloft 50(1), Wellbutrin SR 150(1), Prilosec
20(2), Norvasc 5(1)
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
9. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dose
will change for goal INR [**2-14**], Dr. [**Last Name (STitle) **] to continue to manage
coumadin/INR- have INR drawn on Mon. [**8-14**] with results to Dr.
[**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Serial PT/INR
Dx: atrial fibrillation
Goal INR [**2-14**]
Results to Dr. [**Last Name (STitle) **] (Phone: [**Telephone/Fax (1) 81411**] Fax: [**Telephone/Fax (1) 81412**])
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1514**] Regional VNA
Discharge Diagnosis:
atrial fibrillation, s/p mini-maze
CAD status post RCA stent, sleep apnea, intermittent atrial
arrhythmias which include atrial flutter and atrial
fibrillation. She is status atrial flutter ablation, diabetes,
hypertension, hypercholesterolemia, and depression.
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These included
redness, drainage or increased pain.
2) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
3) Report any fever greater then 100.5
4) No lotions, creams or powders to incisions. You may
wash/shower incisions with soap and pat dry.
5) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 39975**] in 1 month.
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 81411**]
INR on Monday [**8-14**] with results to the office of Dr. [**Last Name (STitle) **]
([**Telephone/Fax (2) 81413**]
Completed by:[**2102-8-12**]
ICD9 Codes: 412, 311, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4503
} | Medical Text: Admission Date: [**2166-9-24**] Discharge Date: [**2166-10-20**]
Date of Birth: [**2144-9-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Cough, dyspnea on exertion
Major Surgical or Invasive Procedure:
TEE
Aortic and mitral valve replacement
History of Present Illness:
Patient is a 22 yo male who presents with worsening cough and
DOE x 3 weeks. His initial symptoms included a nonproductive
cough associated with SOB with exercise. At baseline he is very
active but now becomes dyspnic with 1 flight of stairs. The
cough is worse at night and when lying flat. Reports poor PO
intake over this time with a 25 pound weight loss and drenching
night sweats x 1 week but no fevers or chills. Also had 4-5 days
watery brown diarrhea (non-bloody) last week without abdominal
pain. He was seen at [**Hospital 778**] clinic today and noted to have new
harsh holosystolic murmur and sent to ED for evaluation.
In the ED, noted to be febrile to 102F. CXR w/ bilateral diffuse
interstitial infiltrates. TTE revealed severe LV dilatation,
preserved EF, aortic and mitral vegetations with moderate AR and
severe MR. 3 sets blood cultures were sent. Received vancomycin,
ceftriaxone, and gentamycin. Admitted to CCU for close
monitoring.
Denies h/o IVDU, blood transfusion, needle sticks, or recent
illness. Reports dental cleaning 4 months prior. Had unconfirmed
strep throat approximately 9 months ago. Endorses PND but no
orthopnea or edema. No palpitations, syncope, or presyncope.
Past Medical History:
None
Social History:
[**Location (un) 86**] Conservatory student (plays the cello). Family lives in
MA. Denies tobacco, illicits, or IVDU. EtOH: 1 drink per week. 4
lifetime sexual partners (only women); last intercourse 2 years
ago. No h/o STDs but never tested.
Family History:
No history of SCD or congenital heart disease.
Physical Exam:
T 100.2 HR 123 BP 100/40 RR 23 SaO2 99% on RA
General: WDWN, NAD, breathing comfortably on RA
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: tachycardic, regular, s1s2 normal, +S3, [**4-5**] blowing
holosystolic murmur throughout precordium and radiates to the
neck and back, 1-2/6 diastolic murmur best heard @ LUSB, no JVD
Pulmonary: CTAB (although murmur obscurs exam)
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema, no Osler's nodes,
[**Last Name (un) 1003**] lesions, or splinter hemorrhages
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
ECG ([**9-24**]): sinus tach, 105bpm, normal axis and intervals, no
ST-T changes
Relevant Imaging:
1)CXR ([**9-24**]): Diffuse bilateral interstitial prominence which
given this patient's new heart murmur may represent interstitial
edema from congestive heart failure. Differential diagnosiis
includes an infectious process especially viral pneumonitis
Correlate clinically, with echocardiography and follow up.
2)TTE ([**9-24**]): The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
Three distinct aortic valve leaflets are not clearly seen. The
aortic valve may be bicuspid. The aortic valve leaflets are
thickened and deformed. There is a large vegetation on the
aortic valve. Moderate aortic regurgitation is seen. There is a
large (1.3 x .2 cm) vegetation on the mitral valve. Severe
mitral regurgitation is seen. There may be a mitral valve
perforation. There is a trivial / physiologic pericardial
effusion.
3)TEE ([**9-26**]): The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are 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 is bicuspid. There is a
large vegetation on the aortic valve that prolapses into the
left ventricular outflow tract. No aortic valve abscess is seen.
Moderate to severe (3+) aortic regurgitation is seen. The
anterior mitral leaflet is aneurysmal with perforation in it and
vegetations on it. No mitral valve abscess is seen. Moderate to
severe (3+) mitral regurgitation is seen (via perforation).
There is no pericardial effusion.
4)CT Head ([**9-26**]): No evidence of intracranial hemorrhage or
intraparenchymal changes to suggest septic emboli.
5)CT Abdomen & Pelvis ([**9-26**]):No radiographic evidence of septic
emboli sequelae within the abdomen. No evidence of small bowel
obstruction. Splenomegaly.
6)CT Chest w/o contrast: 1. No radiographic evidence of
esophageal perforation. Oral contrast is present within the
stomach with no evidence of contrast or air elsewhere within the
mediastinum. 2. Bilateral interstitial and air space opacities
predominantly within the lower lobes along with bilateral
pleural effusions likely a component of pulmonary edema.
7)EGD ([**10-1**]):Inflammatory exudate with mucosal sloughing was
seen throughout the esophagus. This is consistant with a
infectous or inflammatory process, fungal being the most likely.
[**2166-10-19**] 05:30AM BLOOD WBC-7.8 RBC-3.69* Hgb-10.1* Hct-29.2*
MCV-79* MCH-27.3 MCHC-34.5 RDW-17.6* Plt Ct-388
[**2166-10-16**] 08:57AM BLOOD WBC-6.1 RBC-3.64* Hgb-9.4* Hct-29.0*
MCV-80* MCH-25.9* MCHC-32.6 RDW-17.5* Plt Ct-417
[**2166-10-20**] 05:01AM BLOOD PT-25.5* PTT-103.2* INR(PT)-2.6*
[**2166-10-19**] 05:30AM BLOOD PT-22.2* PTT-58.6* INR(PT)-2.2*
[**2166-10-18**] 04:48AM BLOOD PT-19.9* PTT-76.8* INR(PT)-1.9*
[**2166-10-19**] 05:30AM BLOOD Glucose-102 UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-102 HCO3-26 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 68464**] is a 22 yo male who presented with a 3 week h/o
fever, SOB, new murmur, aortic and mitral valvular vegetations
on ECHO c/w subacute native-valve endocarditis.
.
1) Endocarditis: Patient was found to have large aortic and
mitral valve vegetations on TTE on admission, which was
consistent with patient's history of fever, cough and new murmur
on physical exam. He was started on Vancomycin, gentamycin, and
ceftriaxone in the ED and ID was consulted. CT surgery was also
consulted and felt that patient was a surgical candidate based
on vegetation size and LV dysfunction. Blood cultures ([**1-8**]
bottles) grew strep viridans. CT scan of the head, abdomen, and
pelvis did not suggest any septic emboli. TEE was done but no
abcess was seen. Surveillance cultures since then have been
negative. Gentamycin and ceftriaxone were d/c'[**Last Name (LF) **], [**First Name3 (LF) **] ID, and he
was maintained on Vancomycin. After the sensitivities were
available the Vancomycin was changed to Ceftriaxone 2gm IV. He
will require at least 6 weeks of therapy from the last positive
blood culture. Daily EKGs were done and did not suggest PR
prolongation or AVB. Patient will undergo aortic and mitral
valve replacement on [**2166-10-6**].
He was taken to the operating room on [**2166-10-6**] where he
underwent an AVR with (27/29 onyx mechanical aortic valve, and
MVR with 31/33 onyx mechanical mitral valve. He was transferred
to the SICU in critical but stable condition. He was extubated
later that same day. He continued on ceftriaxone for his
endocarditis. He was weaned from his vasoactive drips and
transferred to the floor on POD#1. He did well postoperatively.
He was started on heparin and coumadin for his double mechanical
valves. He remained in the hospital awaiting a therapeutic INR
and was ready for discharge on [**10-20**].
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q24H (every 24 hours): continue through
ID appointment [**10-29**].
Disp:*60 grams* Refills:*0*
3. Saline flush
5 ml Normal Saline before and after antibiotics
4. Heparin flush
Heparin flush (100 u/ml) 3 ml after antibiotics
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Warfarin 5 mg Tablet Sig: 2.5 Tablets PO ONCE (Once) for 3
doses: 12.5 mg, check INR [**10-22**] with results to Dr. [**Last Name (STitle) 2912**].
Disp:*90 Tablet(s)* Refills:*0*
10. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 5065**]
Discharge Diagnosis:
AV and MV endocarditis
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 heavy lifting or driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 52830**] 2 weeks
Dr. [**Last Name (STitle) 2912**] 2 weeks
[**First Name8 (NamePattern2) 7618**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2166-10-28**] 9:00
Completed by:[**2166-10-20**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4504
} | Medical Text: Admission Date: [**2141-6-8**] Discharge Date: [**2141-7-4**]
Service: SURGERY
Allergies:
Penicillins / Benadryl
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Diarrhea, rigors
Major Surgical or Invasive Procedure:
Intubation
NGT placement
Central venous lines
Total abdominal colectomy
open cholecystectomy
History of Present Illness:
Ms. [**Name14 (STitle) 55941**] is an 85 yo female with recent hospitalization for
C. diff colitis (from [**Date range (1) 29129**]/08; discharged to rehab; sent
home on [**2141-5-31**]). Today she presented from home with rigors and
diarrhea. The diarrhea has been non-bloody and began 2-3 days
ago; it has not been associated with abd pain/cramping or
nausea/vomiting. This morning she developed rigors and a fever
of 100.7.
In the ED, she was febrile to 102, SBP was in the 80's
initially, and lactate was 3.8. She was started on
vanco/levo/flagyl. She was given 2L NS but blood pressure
remained in the 70 - 80's systolic; a right IJ was placed and
she was placed on a code sepsis, with initiation of levophed.
Of note, on presentation at the last admission, there was
concern for ischemic bowel initially, and she was started on IV
flagyl/vanco and cipro. She was taken off the flagyl and cipro
once stool studies were returned with C. diff, and she completed
a two week course of PO vanco for the C. diff (ended on
[**2141-5-30**]). Her course then was c/b hypotension in the 80's, for
which she received IVF but was never on pressors. Prior to the
[**Month (only) **] hospitalization, she was on Keflex x 1 week for an infected
left toe, as well as doxycycline for Lyme disease.
Past Medical History:
Hypertension
Hypercholesterolemia
Hypothyroidism
H/o pneumonias-- c/b AFib
Right rotator cuff tear-- [**2141-2-4**]; on percocet PRN
Osteoarthritis
Psoriasis
Chronic kidney disease (baseline uncertain; ~1.4 in prior d/c
summary)
Social History:
Social History:
Former smoker, 2ppd x67years (135-pack-years), quit 4years ago.
Occasional EtOH.
Family History:
Adopted and unsure of biological family hx
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: elderly, comfortable but appears tired
Lungs: crackles at bases b/l; otherwise CTA
Heart: soft HS; rate regular; no m.r.g. appreciated
Abd: hyperactive BS; totally soft, NT to deep palpation, no
rebound/guarding
Extremities: [**12-7**]+ LE edema; 1+ distal pulses
Neuro: CN II - XII
.
At Discharge:
Vitals: T-98.9, HR-71, BP-130/70, RR-20, 2LNC-96%
Gen: NAD, A/Ox3
CV: AFIB, no m/r/g
RESP: Congested bases b/l, productive cough, clear otherwise
ABD: +BS, soft, NT/ND
Incision:
Extrem: no c/c/e
Pertinent Results:
ADMISSION LABS:
[**2141-6-8**] 02:50PM BLOOD WBC-21.1* RBC-3.74* Hgb-10.4* Hct-32.0*
MCV-86 MCH-27.8 MCHC-32.5 RDW-14.4 Plt Ct-408
[**2141-6-8**] 02:50PM BLOOD Neuts-74* Bands-10* Lymphs-5* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1*
[**2141-6-8**] 02:50PM BLOOD PT-32.6* PTT-28.8 INR(PT)-3.4*
[**2141-6-8**] 02:50PM BLOOD Glucose-112* UreaN-16 Creat-1.3* Na-130*
K-8.4* Cl-95* HCO3-25 AnGap-18
[**2141-6-8**] 06:00PM BLOOD ALT-11 AST-15 AlkPhos-48 TotBili-0.5
[**2141-6-14**] 04:18AM BLOOD Lipase-31
[**2141-6-8**] 02:50PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2141-6-8**] 06:00PM BLOOD Cortsol-45.7*
[**2141-6-8**] 06:00PM BLOOD CRP-171.6*
.
CARDIAC ENZYMES:
[**2141-6-8**] 02:50PM BLOOD CK(CPK)-150*
[**2141-6-9**] 03:22AM BLOOD CK(CPK)-26
[**2141-6-8**] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2141-6-9**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01
.
MICROBIOLOGY:
[**2141-6-8**] Blood Cultures: two sets, NGTD
[**2141-6-8**] Urine Cultures: negative
[**2141-6-9**] C. diff toxin A: positive
[**2141-6-14**] Blood cultures: two sets, NGTD
.
IMAGING:
[**2141-6-8**] ADMISSION CXR:
No acute cardiopulmonary process. Poorly aerated retrocardiac
region, limiting evaluation of left lower lobe. Lateral views
would aid further evaluation.
.
[**2141-6-9**] CT ABD/PELVIS:
1. Findings consistent with pseudomembraneous colitis. No
pneumoperitoneum or marked dilatation of the transverse colon to
establish toxic megacolon, but clinical correlation is
important.
2. Fibroid uterus, including a cavitating fibroid, but of
doubtful clinical significance.
[**2141-6-14**] TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The estimated cardiac
index is borderline low (2.0-2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. Cannot exclude mild aortic
stenosis, but this does not appear to be severe. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2141-5-15**], the
findings are similar.
.
[**2141-6-23**] CT CHEST: Persistent, extensive, and severe emphysema is
observed. There is increase in the bilateral effusion with
moderate atelectatic changes as compared to the previous CT. The
NG tube and endotracheal tubes are seen in place. There are mild
left lower lobe infiltrative changes. Two right lower lobe
non-calcified pulmonary nodules are seen, which are 6 mm in size
(series 2, image 40).
.
[**6-27**] CXR: Worsening pulmonary vascular congestion with probable
bilateral
pleural effusions.
.
[**2141-7-4**] 07:30AM BLOOD PT-13.1 INR(PT)-1.1
Brief Hospital Course:
[**6-9**]- 85 yo female with recent admission for C. diff colitis,
admitted with sepsis in the setting of recurrent diarrhea.
Sepsis/Fevers/Leukocytosis from recurrent C. diff given severely
elevated WBC. Hyponatremia of 130 on admission; likely
hypovolemic in setting of sepsis treated with NS. UA on
admission weakly c/w infection but pt asymptomatic; CXR with
possible b/l infiltrates but more likely atalectasis given small
lung volumes and lack of [**Last Name (un) **] sx. Pt thought to have ischemic
bowel with possible gut translocation.
[**6-10**]- Taken to OR for Total abdominal colectoym and
cholecystectomy. PT remained intubated and was transferred to
the [**Hospital Unit Name 153**] for ICU monitoring. Urine, blood cultures. C. diff
assay and covereage with vanco/flagyl IV as well as cipro
started. CVP maintained from 10 - 12, with boluses of IV NS to
maintain. BP maintained with levophed. Fentanyl and versed
boluses fo pain control. UOP maintained 20-30 cc per hr.
[**Date range (1) 25044**] weaned off pressors. Continued reusctiation with IVF.
PT in AFib throughout course at [**Hospital1 18**] rate controlled to low
100s with lopressor.
[**6-14**] -11: [**Month/Day (4) **] diuresis with IV lasix. TPN started.
[**6-17**]- [**6-21**] Elevated WBC, tube feeds begun adn advanced to goal.
Vent weaned as tolerated with prolonged difficulty weaning from
vent, continued diuresis. Fever workup unrevealing.
[**6-23**]: WBC down, has not been afebrile 24 hours; suspect
transient bacteremia from central line; [**6-23**] CT torso
unrevealing. Pt placed on vanco IV for presumed line infection
and IV flagyl for c. diff; Central line changed [**6-23**]. Pt
treated with PRN lasix to volume goal -2L x 24 hrs. Started on
liquid diet. transferred to the floors
[**6-24**] Staples removed from abdominal wound, steristrips placed.
[**6-25**]: extubated without difficulty or complication.
[**2141-6-26**] Tolerating respiratory criteria. Placed on oxygen to
help with breathing.
Liquid diet started with aspiration precautions.
[**6-27**] Regular diet with aspiration precattions.
[**2141-6-28**]. Pt transferred to surgical floors. Placed on [**1-9**] L of
oxygen. Progressed to regular diet. Calorie counts initiated to
aim at daily caloric and protein requirements. Patient was
re-tested for C.diff and was negative. Ample stool and gas
through ostomy bag. Rehabilitation screen initiated to assist
with patient conditioning.
[**6-29**]: Pt devoloped rash c/w hives. Sarna lotion applied to
decreased discomfort. Pt allergic to benadryl and
anticholinergic risk thought to outweigh benefit of hydoxizine.
[**2141-6-30**]: PT's roxicet discontinued due to concern of sundowning.
Improved cognition once narcotic dc'd. Itching temporarily
relieved.
[**Date range (1) 20941**]: Pt continued to recuperate. [**Name (NI) **] PT continued.
Tolerating regular diet and Ensure supplements. No sign of
aspiration. Continue to monitor as precaution.
[**7-3**]:Plans to send patient to rehab for conditioning, awaiting
available REHAB bed. Coumadin started. INR monitored for
adjustments. Patient OOB with PT and Nursing. Fatigued by end of
day, knees buckled during transfer from Chair to Bed. Patient
gently guided to floor. No trauma or injury sustained.
Transferred back to bed safely. Continue to monitor for FALL
risk.
[**7-4**]: INR-1.1 today. Continue Coumadin dose titration. Rehab bed
available. Patient remains stable, and cleared for transfer to
Rehab today.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient):
Primidone 100 mg QD
Nexium 40 mg QD
Aspirin 325 mg QD
Hexavitamin QD
Ferrous Sulfate 325 mg QD
Percocet 5-325 mg PRN
Levothyroxine 100 mcg QD
Metoprolol Tartrate 25 mg [**Hospital1 **]
Lasix 40 mg QD
Lisinopril 40 mg QD
Coumadin
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for anxiety.
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: 20mL PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 4000mg in
24hours.
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)) as needed for Atrial Fibrillation: Adjust dose
according to INR. Goal INR = [**1-8**].
9. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia: Hold for somnolence.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Give with meals .
12. Primidone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate up to 40mg (usual dose) as indicated. Hold for HR <55 or
SBP < 100 .
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): hold for HR <55 or SBP < 100 .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary:
Medically refractory Clostridium difficile colitis
Sepsis-fever and leukocystosis
Post-op respiratory failure-ventilatory dependency
Post-op Atrial fibrillation
Post-op tachycardia
Toxic Megacolon
Acute Renal Failure
.
Secondary:
HTN, hypercholesterolemia, hypothyroidism, PNA, Afib, R rotator
cuff tear, OA, psoriasis, CKD, Parkinson's Disease
Discharge Condition:
Stable
Tolerating regular diet, and Ensure supplements. Aspiration
Precautions.
Pain well controlled with oral non-narcotic medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
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.
.
HTN/AFIB Management:
-Patients taking 40mg of PO Linisopril prior to surgical
admission. Discontinued during admission.
-Lopressor dose increased for rate control related to Atrial
Fibrillation.
-Titrate Lisinopril back up to pre-admission dose as blood
pressure tolerates.
-Consult with Primary doctor with concerns.
-Titrate Lisinopril and Lopressors as needed.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 9**] in [**12-7**] weeks.
2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1549**] [**Telephone/Fax (1) 55940**] one
week after discharge from REHAB.
3. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] (Neurologist)
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2141-7-10**] 4:00
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. (Cardiology)
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-9-20**] 11:20
Completed by:[**2141-7-4**]
ICD9 Codes: 0389, 5185, 5849, 5180, 5119, 9971, 2761, 5859, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4505
} | Medical Text: Admission Date: [**2174-10-14**] Discharge Date: [**2174-10-17**]
Date of Birth: [**2129-10-19**] Sex: M
Service: MEDICINE
Allergies:
Latex / Methotrexate
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44yo M PMHx significant for Lupus, ESRD on HD
(Tues/Thurs/Saturday) awaiting renal transplant, CHF w severe
mitral regurgitation and pHTN, HTN, GERD who initially presented
to [**Hospital 1474**] Hospital with 1 week of SOB and chest pain, workup
significant for flat cardiac enzymes, unremarkable CXR, BNP of
773; patient reports that over the last year, he has had
recurrent episodes of these symptoms that have been attributed
to his mitral valve disease. Review of his [**Location (un) 2274**] notes confirm
this (stays on [**11-2**]), and describe chronic worsening of
his dyspnea on exertion. Workup in the past has included TTE (EF
55-60%, moderate-severe AI, severe posteriorly-directed MR, and
severe pulmonary HTN), Chest CT (c/w interstitial lung disease).
On his admission to OSH, there was concern for need for MVR
workup. Patient now transfered to [**Hospital1 18**] for further management.
.
On arrival, he reported some stable shortness of breath. He
described his symptoms as the sensation that he was not getting
enough air. He reported that his symptoms would often improve
with morphine. He denied any associated chest pain, productive
cough, headache, dizziness.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- Severe mitral regurgitation, pulmonary hyptertension (no
reports available)
3. OTHER PAST MEDICAL HISTORY:
- Lupus
- ESRD on HD (Tues/Thurs/Saturday)
- GERD
Social History:
Lives with 6 year old son in [**Name (NI) 1474**]. Has good relationship
with ex-wife. Retired. [**Name2 (NI) **] smoker with 30pk-yr smoking
history. Denies etoh, illicits. Mother recently died of bonce
cancer.
Family History:
Several family members w autoimmune disorders.
Physical Exam:
ON admission:
VS: 84 79/53 100% with taking NRB on and off throughout
conversation
GENERAL: NAD, comfortable
HEENT: PERRL, EOMI, OP clear
NECK: Supple, no JVD
CARDIAC: RRR, III/VI holosystolic murmur, loudest at apex, w
loss of S2
LUNGS: Resp unlabored, no accessory muscle use, CTA b/l, no
wheezes/rales/rhonchi
ABDOMEN: Soft, NT/ND.
EXTREMITIES: No c/c/e.
SKIN: dry skin
PULSES: DP 2+ PT 2+ bilaterally
.
On discharge:
VS: 98.1/97.6, HR 73-74 SR, RR 18-20, BP 111-117/68-72 O2 sat:
100% RA.
GENERAL: NAD, comfortable
HEENT: PERRL, EOMI, OP clear
NECK: Supple, no JVD
CARDIAC: RRR, III/VI holosystolic murmur, loudest at apex,
LUNGS: Resp unlabored, no accessory muscle use, Dry crackles b/l
bases
ABDOMEN: Soft, NT/ND.
EXTREMITIES: No c/c/e.
SKIN: dry skin
PULSES: DP 2+ PT 2+ bilater
Pertinent Results:
On admission:
[**2174-10-14**] 09:25PM BLOOD WBC-5.6 RBC-3.50*# Hgb-9.9* Hct-31.4*#
MCV-90 MCH-28.2 MCHC-31.4 RDW-18.3* Plt Ct-203
[**2174-10-14**] 09:25PM BLOOD PT-17.4* PTT-28.2 INR(PT)-1.5*
[**2174-10-14**] 09:25PM BLOOD Glucose-131* UreaN-22* Creat-4.7*# Na-137
K-4.6 Cl-97 HCO3-26 AnGap-19
[**2174-10-14**] 09:25PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
On discharge:
[**2174-10-17**] 07:00AM BLOOD WBC-8.0 RBC-3.40* Hgb-9.3* Hct-30.1*
MCV-89 MCH-27.4 MCHC-30.9* RDW-18.0* Plt Ct-243
[**2174-10-17**] 07:00AM BLOOD Glucose-76 UreaN-72* Creat-10.2*# Na-139
K-3.9 Cl-98 HCO3-25 AnGap-20
[**2174-10-15**] 05:19AM BLOOD CK(CPK)-44*
[**2174-10-14**] 09:25PM BLOOD CK(CPK)-51
[**2174-10-15**] 05:19AM BLOOD CK-MB-1 cTropnT-0.02*
[**2174-10-17**] 07:00AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.1
.
ECHO [**10-15**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is mild regional left ventricular systolic
dysfunction with probable thinning and hypokinesis of the basal
inferior segment. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Mild to
moderate ([**11-28**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: the basal inferior wall is probably hypokinetic.
There is moderate to severe mitral regurgitation. Mild to
moderate aortic regurgitation. Moderate pulmonary artery
systolic hypertension.
.
CXR [**10-15**]:
FINDINGS: The lung volumes are low. There is moderate
cardiomegaly with mildpulmonary edema. In addition, relatively
extensive bilateral areas of
opacities are seen that could be atelectatic, but could also
represent
pneumonia. These opacities are more severe on the right than on
the left. Nopleural effusions. A double-lumen left-sided central
venous access line.
Brief Hospital Course:
# Shortness of Breath - Patient w chronic worsening of shortness
of breath, thought to be [**12-29**] mitral regurgitation; patient
denying any chest pain. R/O'd at [**Hospital 1474**] hospital. EKG not
consistent with ischemic origin; no signs to suggest infection
on history, imaging, labs; does not appear to be acute worsening
of MR, but more slow progression. Ground glass appearance on
chest CT and bilat pleural effusions may be suggestive of
interstitial lung disease and may be somewhat responsible for
DOE. Also, pt has hx of OSA and not currently using CPAP which
may be causing moderate pulmonary hypertension seen on ECHO.
Cardiac surgery saw pt today and recommeneded further testing
via cardiac catheterization and TEE to better evaluate valve.
PCP also [**Name (NI) 653**] by [**Name (NI) 2274**] cardiologist [**First Name8 (NamePattern2) **] [**Name (NI) 2920**] to arrange
pulmonary f/u appt to assess above pulmonary issues. Pt was
walked on day of discharge and displayed no DOE with O2 sats in
high 90's.
.
#H/O graft thrombus: pt was not being followed by PCP or
[**Hospital3 **] since moving from [**Hospital1 1474**] to [**Hospital1 392**]. He
states he has been taking warfarin 5 mg regularly (a dose that
he was therapeutic on previously). Dr. [**First Name (STitle) 2920**] has [**First Name (STitle) 653**] PCP to
[**Name9 (PRE) 107265**] [**Name Initial (PRE) **]/u with [**Hospital 2274**] [**Hospital3 **] after discharge.
INR 1.6 on discharge, 5 mg dose was continued.
.
# GERD: no issues, will cont PPI [**Hospital1 **].
.
# Lupus: pt states he is in a flare but able to ambulate with a
cane and no increase in pain medicines needed. He has a
rheumatologist in [**Hospital1 1474**] where he previously lives who told
him to increase prednisone to 20 mg with a taper down to 5 mg
over one week. Apparently, pt has a soft diagnosis of lupus per
[**Location (un) 2274**] notes. No changes were make in his medicines (including
oxycodone) and Dr. [**First Name (STitle) **] will arrange rheumatology through
[**Location (un) 2274**].
.
# ESRD on HD: Scheduled Tues/Thurs/Sat. Rec'd HD today without
incident and removed 2L total. Appears euvolemic on exam.
Unclear if more aggressive fluid removal in HD has helped his
SOB.
.
# HTN: BP well controlled at present on atenolol. No ACE on
admission.
.
# Insomnia / Anxiety; Trazadone and lorazepam were continued at
home doses.
.
Transitional issues:
1. Pt was counseled to continue care at [**Location (un) 2274**] and seek referrals
for rheumatology and pulmonology within that system. AS he is a
young complicated pt, he would benefit from an integrated health
care system.
2. PCP will arrange [**Name Initial (PRE) **]/u in [**Hospital3 **] for INR
monitoring.
3. PCP will arrange [**Name Initial (PRE) **]/u with pulmonology to evaluate sleep apnea
and pulmonary hypertension
4. Cardiac surgery will arrange cardiac catheterization and TEE
as an outpt in preparation for MVR.
Medications on Admission:
- Chloroquine 250mg daily
- Albuterol / ipratropium inhaler
- ASA 81mg daily
- B complex / Folic Acid
- Atenolol 50mg daily
- Nexium 40mg [**Hospital1 **]
- Fluticasone INH 2 spray
- Coumadin 5mg daily
- Oxycodone 15mg q4hrs prn pain
- Ativan 2mg [**Hospital1 **] prn anxiety
- Trazodone 50mg qhs prn insomnia
- Prednisone 5mg daily
Discharge Medications:
1. chloroquine phosphate 250 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4
hours) as needed for pain: no more than 6 doses per day.
9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for insomnia, anxiety.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain: do not
take more than 2 tablets 5 minutes apart. .
Discharge Disposition:
Home
Discharge Diagnosis:
Mitral Valve Disease
Lupus
Chronic Diastolic Congestive heart failure
Hypertension
End stage renal disease.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were having trouble breathing and was transferred from
[**Hospital 1474**] Hospital to [**Hospital1 18**] to be evaluated by cardiac surgery
for a potential valve replacement or repair. We have continued
your dialysis treatments and home medicines. You will need to
see a lung doctor (pulmonologist) before surgery to see if your
breathing difficulties may be because of lung issues in addition
to your heart valves. We have [**Hospital1 653**] Dr. [**First Name (STitle) **] to set up
coumadin monitoring through [**Hospital1 **] and she will also
refer you to a pulmonary doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 392**]. The cardiology
surgery team will contact you at home to schedule the two tests,
cardiac catheterization and echocardiogram via the esophagus.
We did not make any changes to your medicines, please continue
to take coumadin 5 mg every day
Followup Instructions:
[**10-24**] at 11:20AM at [**Hospital1 392**] [**Location (un) 2274**] with Dr. [**Last Name (STitle) 88768**]
[**Name (STitle) 10102**]. She will refer you to a lung specialist at [**Location (un) 2274**].
.
[**Hospital3 **] at [**Location (un) 2274**]: they will contact you tomorrow
and will tell you how much coumadin to take every day.
.
The cardiac surgery department will call you at home to schedule
a cardiac catheterization and esophageal echocardiogram in the
near future.
.
Department: TRANSPLANT SOCIAL WORK
When: FRIDAY [**2174-10-28**] at 10:30 AM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: FRIDAY [**2174-10-28**] at 9:00 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
ICD9 Codes: 4240, 5856, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4506
} | Medical Text: Admission Date: [**2189-3-12**] Discharge Date: [**2189-3-18**]
Service: SURGERY
Allergies:
Penicillins / aspirin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F s/p with hx of HTN and hyperlipidemia presenting s/p fall
off stepladder while while cleaning the top of the refrigerator.
Fell backwards onto back and left side of her head. No LOC, no
CP, no SOB. Presented to LGH where a CT head showed a possible
frontal contusion vs bleed. CT C spine showed grade 1
anterolithesis of C6 on C7 by 3mm, no acute fracture. CXR showed
mildly displaced fractures of lateral aspect of L fourth, fifth,
sixth ribs. Interstitial changes with probable mild superimposed
pulmonary edema.
The pt was transferred to [**Hospital1 18**] for trauma evaluation. In the ED
a CT of the chest was performed as well as plain films of the
T-spine and the left humerus.
The pt was seen by neurosurgery for her closed head injury.
their recommendations included close neuro checks. Pt was
admitted to the TSICU for polytrauma in stable condition.
Past Medical History:
PMH: Hypothyroidism, HTN, GERD, HL, Chronic dizziness
PSH: Appendectomy, Tonsillectomy
Social History:
Retired. former smoker, no EtOH
Family History:
non-contributory
Physical Exam:
Admission physical:
O: T: 97.3 BP: 170/78 HR: 80 R 18 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**1-16**], equal EOMs intact. small post head
laceration
Neck: Supple.
Lungs: CTA bilaterally. tender to palpation L hemithorax
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
[**Month/Day (2) 1105**], IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-21**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
normal bilaterally
Toes downgoing bilaterally
Exam on discharge [**2189-3-18**]:
VS: 98.4 62 160/64 16 96% on 2L NC
Neuro: A&OX3, PERRLA, +MAE, speech fluent and clear
CV: RRR
Pulm: crackles @ bases bilaterally, left chest wall tender to
palpation laterally
Abd: soft, nontender, nondistended
Extr: No edema, +PP. Warm, pink and well perfused.
Pertinent Results:
[**2189-3-12**] 04:00AM WBC-7.1 RBC-4.47 HGB-8.9* HCT-30.3* MCV-68*
MCH-20.0* MCHC-29.5* RDW-15.3
[**2189-3-11**] 09:10PM PLT COUNT-200
[**2189-3-11**] 09:10PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.7
[**2189-3-11**] 09:10PM GLUCOSE-121* UREA N-29* CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-17* ANION GAP-18
[**3-12**]- CT chest
1. Fractures involving posterior left 4th, 5th and 6th ribs. No
pneumothorax.
2. Small bilateral nonhemorrhagic pleural effusions with
adjacent compressive atelectasis.
3. BL pulmonary nodules, larges measuring 6x 7mm, f/u CT in [**4-28**]
mo if low risk pt.
4. cholelithiasis no cholecystitis.
5. extensive calcified atherosclerotic disease, no aneurysms.
TTE report [**2189-3-12**] - The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF 60%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. 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. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
[**2189-3-15**] ECG
Sinus rhythm. Inferior and lateral ST-T wave abnormalities.
Compared to the previous tracing of [**2189-3-12**] inferior myocardial
infarction pattern is less evident but ST-T wave abnormalities
are more pronounced.
[**2189-3-15**] Chest x-ray:
Since the previous study, there has been worsening of the
pulmonary
interstitial densities likely related to pulmonary edema.
However, the
vascular pedicle is not widened. Underlying infection is not
excluded. There is increase in the left-sided pleural effusion
since the previous study. There has also been development of a
small right-sided pleural effusion. Calcification in thoracic
aorta is identified.
[**2189-3-16**] Chest x-ray:
Acute interstitial pulmonary abnormality that worsened
appreciably between [**3-13**] and 29 has subsequently improved.
The course is most consistent with pulmonary edema, cardiogenic
or otherwise. Persistent consolidation at the lung bases could
be due to atelectasis. Small-to-moderate left pleural effusion
has decreased since it progressed between [**3-13**] and 29. Heart
is mildly to moderately enlarged as before, but mediastinal
veins are no longer distended. No pneumothorax.
[**2189-3-16**] Renal US:
1. Bilateral simple renal cysts, measuring up to 1.4 cm in the
right lower pole. No evidence of renal calculi, hydronephrosis,
or mass.
2. Bladder contains a Foley and is poorly visualized due to
being empty.
Labs at discharge:
[**2189-3-18**] 05:50AM BLOOD WBC-5.5 RBC-4.01* Hgb-8.0* Hct-27.0*
MCV-67* MCH-20.0* MCHC-29.7* RDW-15.3 Plt Ct-256
[**2189-3-18**] 05:50AM BLOOD Plt Ct-256
[**2189-3-18**] 05:50AM BLOOD Glucose-84 UreaN-41* Creat-1.6* Na-137
K-4.1 Cl-105 HCO3-22 AnGap-14
[**2189-3-18**] 05:50AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8
[**2189-3-18**] 01:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2189-3-18**] 01:46AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2189-3-18**] 01:46AM URINE Mucous-RARE
[**2189-3-18**] 01:46AM URINE Hours-RANDOM UreaN-379 Creat-43 Na-70
K-13 Cl-61
Brief Hospital Course:
Ms [**Known lastname **] was admitted to the Trauma ICU in the early hours of
[**2189-3-12**]. She arrived awake and alert with left chest pain her
primary complaint. To address her left chest pain, she was given
tylenol and oxycodone with good result. She was encouraged to
deep breathe with incentive spirometry and had a minimal oxygen
requirement (0-2L).
On presentation she had a small elevation of troponin. This
peaked at 0.57 at EKG showed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1105**], [**First Name3 (LF) **] depression V3-V5. The
V3-V6 leads showed deeper ST depressions soon after, then
resolving. An echo showed normal function (see pertinent results
section). She was followed closely by cardiology who recommended
restarting her home aspirin but no further intervention.
By HD 2, she was fully oriented, tolerating a regular diet, on
minimal oxygen and with pain well controlled. Given her age and
high risk of developing pulmonary complications, she was further
monitored in the hospital on the surgical floor but was
transferred out of the TICU to the floor on [**2189-3-13**]. On the
floor her vital signs were routinely monitored and her daily
labs were trended. Her creatinine continued to rise from 1.1 on
admission to 1.5 on [**3-14**]. Urine electrolytes were obtained that
indicated the patient was prerenal and dry and so she was given
a bolus of IV fluids. Also of note, her troponin continued to
rise to 0.93, but this was in the setting of acute kidney injury
with elevation in creatinine and thought to be unlikely to do a
cardiac etiology. With the IV fluids she developed flash
pulmonary edema and was transferred back to the TICU on [**2189-3-15**]
with respiratory compromise. Lasix was given and she was started
[**Female First Name (un) **] nitro gtt. She was placed on intermittent CPAP, which was
able to be weaned with diuresis and the nitro gtt was
subsequently turned off. On [**2189-3-16**] her respiratory status was
stable on minimal nasal cannula and her chest x-ray showed
significant improvement in edema (See pertinent results for
details). Therefore, she was again transferred back to the
surgical floor.
Neurosurgery was consulted on admission for her right frontal
IPH who recommended no need for antiseizure prophylaxis and
outpatient follow up one month from discharge. She remained
alert and oriented x 3 throughout her hospital course.
Her pain level was routinely assessed and controlled with an
oral pain regimen.
The nephrology service was consulted for continued rise in
creatinine up to 1.9 on [**2189-3-16**]. A renal ultrasound was obtained
which showed simple renal cysts but no evidence of renal
calculi, hydronephrosis, or mass. Given that the patient had
prior evidence of chronic renal insufficiency with a documented
creatinine of 1.6 one year a few months ago and was clinically
"dry" on exam, it was recommended that she be given IV fluids at
a slow rate in order to rehydrate and avoid pulmonary edema. It
was also recommened to hold her gemfibrozil and change her home
PPI to an H2 blocker which was done. On [**2189-3-17**] she was ordered
for a 500 cc bolus of normal saline of 8 hours, which she
tolerated without respiratory compromise. Her foley catheter
remained in place for urine output monitoring, which remained
adequate. On [**3-18**] her serum creatinine has come down toward
baseline of 1.6. Final renal recommendations were to hold her
gemfibrozil until [**3-20**] and recheck her serum creatinine at that
point. If her creatinine is stable on [**3-20**] her gemfibrozil can be
restarted at that time.
Incentive spirometry and pulmonary toileting were continued,
along with scheduled nebulizer treatments. With this, her oxygen
saturation remained within normal limits on minimal nasal
cannula supplementation.
Physical therapy was consulted on admission to evaluate the
patient's mobility, who recommended transfer to rehab to
continue recovery when medically cleared. The patient was
encouraged to mobilize out of bed as tolerated throughout her
stay, and was started on SC heparin for DVT prophylaxis 48 hours
after her injury.
On [**2189-3-18**] she is afebrile and hemodynamically stable. Her pain
is well controlled and she is tolerating a regular diet. Her
respiratory status is stable and she is making adequate amounts
urine. She is being discharged to acute level rehab to continue
her recovery.
Medications on Admission:
Meclizine 25 mg PRN, Atenolol 50 mg daily, Amlodipine 5 mg
daily, Nitroglycerin PRN, Omeprazole 20 mg daily, Isosorbide
mononitrate 60 mg daily, Synthroid 50 mcg daily, Gemfibrozil 600
mg [**Hospital1 **]
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. isosorbide mononitrate 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
3. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): *Hold until [**3-20**]. Recheck serum creatinine [**3-20**] and
restart if creatinine stable at 1.6 or less.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left lateral chest.
11. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-17**] Sprays Nasal
QID (4 times a day) as needed for congestion.
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
15. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p fall
Injuries:
1. Left lateral rib fractures [**2-20**]
2. Small Right frontal IPH
Acute Kidney Injury
Acute Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall. You sustained
multiple left-sided rib fractures and a small bleed in your head
which is stable. You are now being discharged to rehab to
continue your recovery.
Some of your medications have been changed because of your
kidney function while you were in the hospital. Your gemfibrozil
is being held for how and your omeprazole has been discontinued
and changed to famotidine. Please discuss your medication
regimen with the healthcare providers at your rehab facility
prior to going home.
You sustained rib fractures which can cause sever pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedation, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the samll
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Unless directed by your doctor, DO NOT take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen, etc.
Followup Instructions:
Name:[**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Primary Care
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**]
Phone: [**Telephone/Fax (1) 34574**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2189-4-2**] at 2:15 PM
With: ACUTE CARE CLINIC with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Department: RADIOLOGY
When: TUESDAY [**2189-4-28**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2189-4-28**] at 10:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2189-3-18**]
ICD9 Codes: 5845, 4019, 2724, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4507
} | Medical Text: Admission Date: [**2140-9-21**] Discharge Date: [**2140-10-12**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
gentleman who presented to the hospital on [**2140-9-21**] with
complaint of palpitations, chest heaviness and shortness of
breath. On presentation in the Emergency Department he was
found to be hypoxic with an oxygen saturation of 80% on room
air. He had a chest x-ray which showed bilateral
infiltrates, question of pneumonia versus pulmonary edema.
He was treated with pneumonia with Levaquin. Cardiac enzymes
were sent, returning several hours later showing a CK of 690,
MB of 48, MB index of 7 and a troponin of 47. He was
heparinized for potential catheterization and subsequently
had worsening hypoxia and hypotension necessitating elective
intubation. He was started on dopamine and ETT. He was
subsequently transferred to the Coronary Care Unit for
further management.
PAST MEDICAL HISTORY: Diabetes mellitus, hypertension,
monoclonal gammopathy of unknown significance, peripheral
vascular disease status post right femoral to dorsalis pedis
bypass, and status post appendectomy.
SOCIAL HISTORY: The patient is a former cigar smoker, no
alcohol. He is married. His wife is demented and was
recently placed in a [**Hospital 4820**] nursing care facility. He
lived at home with VNA assistance.
MEDICATIONS ON ADMISSION: Aspirin 81 mg once daily;
lisinopril 20 once daily; Zoloft 50 once daily; glyburide 2.5
once daily; Norvasc 5 once daily; Lopressor 25 b.i.d.
ALLERGIES: The patient has no known drug allergies..
PHYSICAL EXAMINATION: On presentation the patient was
afebrile and had a blood pressure of 92/60. Blood pressure
was 92/60 on 15 of dopamine. Pulse was 119. The patient was
on the vent assist control, tidal volume 600, respiratory
rate 16, PEEP of 10, FIO2 of 1, saturating 99%. Generally he
was a thin elderly gentleman intubated and sedated. Head,
eyes, ears, nose and throat: The patient had thin pink
secretions coming from his endotracheal tube, jugular venous
pressure was 6-7 cm. Chest: He had diffuse coarse rhonchi
anteriorly, no wheezing, no crackles. Cardiovascular:
Tachycardic with distant heart sounds, no appreciable
murmurs. Abdomen: Soft, nontender, and nondistended with
normal active bowel sounds. Extremities: The right groin
had a bypass surgical scar. The patient did not have
palpable dorsalis pedis or posterior tibial pulses
bilaterally, although they were dopplerable. The patient had
1+ edema bilaterally at the ankles.
LABORATORY DATA: White blood cell count on admission was
12.6 with a differential of 89 neutrophils, no bands.
Hemoglobin was 33%. Labs: 143/4.2, 108/21, 68/2.3 which is
an increase from 0.9. The patient's lactate was 4.7 and his
CK was 690, CK MB 48, MBI 7, troponin 47. Blood cultures
were pending.
Chest x-ray showed bilateral lower lobe infiltrates.
Electrocardiogram showed sinus tachycardia with left bundle
branch.
IMPRESSION: This is a [**Age over 90 **]-year-old gentleman with a history
of diabetes mellitus, peripheral vascular disease and
hypertension admitted to the Coronary Care Unit with acute
myocardial infarction, respiratory distress likely secondary
to pneumonia and acute renal failure.
HOSPITAL COURSE: Cardiovascular: The patient was found to
have acute myocardial infarction. He ruled in by enzymes on
[**9-21**] and [**9-22**]. His enzymes were trending down until [**9-23**]
when he was extubated. The patient failed extubation and
subsequently had a bump in his enzymes again. The patient
was taken to the catheterization laboratory where his right
coronary artery was stented. He remained stable, was weaned
off pressors, and was successfully extubated on [**10-4**]. He
did well extubated and was hemodynamically stable until [**10-7**]
at which time he became acutely short of breath and was found
to be in pulmonary edema. The patient responded to diuresis,
however his enzymes were found to have bumped again. The
patient ruled in for myocardial infarction by enzymes yet
again and had no changes in his electrocardiogram again. The
patient subsequently developed cardiogenic shock with anuric
renal failure and at that point was made DNR/DNI by his
family. The patient was maintained on pressors until [**10-11**]
at which time the family decided to make him comfort care
only. The patient was started on morphine drip, titrated to
comfort, and had asystolic arrest on the morning of [**2140-10-12**].
Pulmonary: The patient had bilateral methicillin-resistant
Staphylococcus aureus pneumonia throughout the course of his
stay that was treated with vancomycin. The patient's
ischemia was thought likely to be secondary to increased
demand on his myocardium secondary to respiratory distress
and increased ortho breathing from his pneumonia.
Renal: The patient had acute renal failure upon admission
which subsequently resolved with normal urine output.
Following his second bump in enzymes he again had some
increase in his creatinine but maintained good urine output.
Following his third bump of enzymes the patient became
increasingly anuric despite pressors with BUN and creatinine
trending upward and a urine output that dwindled to as low as
100 cc a day.
The patient was noted to be in asystole on the morning of
[**2140-10-12**]. He had been bradycardic and hypotensive throughout
the night on his morphine drip and off pressors. His family
was with him at the bedside. His pupils were fixed and
dilated. There was no pulse, no heart sounds were present
and the patient had no breath sounds bilaterally. He was
pronounced dead at 10:10 AM on [**2140-10-12**].
DR.[**Last Name (STitle) 2052**],[**First Name3 (LF) 2053**] 12-462
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2140-10-12**] 10:45
T: [**2140-10-12**] 11:47
JOB#: [**Job Number 37205**]
1
1
1
DR
ICD9 Codes: 5849, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4508
} | Medical Text: Admission Date: [**2106-7-6**] Discharge Date: [**2106-7-13**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Scheduled cardiac cath for stable angina
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
87 year old female with history of CAD, MI, and prior placement
of cypher stent in her RCA on [**2106-3-29**]. After the cath she
reports that she her symptoms improved, but for the past couple
months she has had several episodes of the sensation that
someone is "squeezing her chest." She has had three of these
episodes in the last couple months, which occur at rest. The
most recent was yesterday where she developed the chest
"squeeze", SOB, nausea and bilateral shoulder pain. She denied
any diaphoresis with this epidose. It lasted for a couple
minutes, was relieved partially with one nitro, and completely
with the second nitro. She was admitted today for an elective
cath and during the procedure she was found to have one vessel
CAD in her LAD with 70% proximal stenosis and 80% distal
stenosis. Successful PTCA and Cypher stent in LAD. Her right
and left heart filling pressures were moderately elevated and
her CI was low at 2.0 on Dopamine gtt. She was also noted to
have a long Type A dissection with good flow. Given her poor
cardiac output an IABP was inserted with good systolic
augmentation. Patient was then admitted to CCU.
On ROS:
+ weakness and fatigue for the last few months
+ constipation - last BM 3 weeks ago, still passing flatus
no new cough, nausea, decrease in appetite, abdominal pain,
dysuria, or increased urinary frequency
Past Medical History:
DDI Pacemaker placed [**5-29**]
Hx of Digoxin Toxicity
Appendectomy
Cholecystectomy
Arthritis
Afib
Hernia repair
Hard of hearing
Allergies:
Codeine: GI upset
Social History:
Patient lives in [**Location 620**] MA, next door to one of her sons. She
does not use tobacco or alcohol. The patient walks with a cane
and walker.
Family History:
Her father died in his 80's of "old age" and her mother died of
cancer at 52 years old. No history of CAD.
Physical Exam:
Vitals: WT 55 kg T 96.0 BP 110/49 HR 63 RR 12 PO2 92% RA
Gen: pleasant elderly woman, resting flat in bed, in NAD
HEENT: MM dry, EOMI, right pupil asymmetric, left pupil round,
both reactive to light
Neck: no JVD
CV: RR, nl S1, S2, no MGR
Pulm: CTAB anteriorly, no w/c/r
Abd: + BS, soft, NT, ND
Ext: no peripheral edema
Skin: purpura on upper extremities,
Neuro: AAOx3, CN II-XII intact, no focal abnormalities with
exception of asymmetric pupils
Pertinent Results:
Admission Labs [**2106-7-6**]:
ABG: pH 7.31 pCO2 42 pO2 110 HCO3 22 Hgb:10.9 CalcHCT:33 O2Sat:
97
.
11.0 > 12.4/37.2 < 211 MCV=92
.
142 / 102 / 47
---------------< 117
4.1 / 29 / 1.3
.
PT: 11.7 PTT: 23.4 INR: 0.9
.
CK: 34 MB: Notdone Trop-*T*: <0.01
.
CATH RESULTS [**2106-7-6**]:
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful stenting of the LAD.
COMMENTS:
1. Coronary angiography showed single vessel CAD. The LMCA had
mild
tapering. The LAD was diffusely diseased with a 70% proximal
stenosis
extending to D3, which has an 80% stenosis distally. The LCX had
no
flow-limiting lesions. The RCA stent was widely patent with a
70-80%
stenosis of the last major RPL branch.
2. Resting hemodynamics showed normal central aortic pressures,
moderately elevated right and left heart filling pressures and a
mildly
depressed cardiac index (2.0, on Dopamine gtt).
3. Successful PTCA and stenting of the LAD with three 2.25 mm
MiniVision stents and a 2.5 mm Cypher drug-eluting stent, which
was
post-dilated to 2.75 mm. Final angiography showed no residual
stenosis,
a long Type A dissection with good flow (see PTCA comments).
4. A 7 French 30 cc IABP was inserted with good systolic
augmentation.
.
ECHO RESULTS [**7-7**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed with global hypokinesis and akinesis of the distal
septum and apex. LVEF of 30-35%. No LV mass/clot seen. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-27**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a small to moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared to the prior report (tape unavailable for reviewe)
dated [**2105-6-23**], the regional/global LV systolic dysfunction is
new. The pericardial effusion is probably similar.
.
ECHO RESULTS [**7-12**]:
Overall left ventricular systolic function is moderately
depressed. Left Ventricle - Ejection Fraction: 30% to 35%.
Right ventricular chamber size and free wall motion are normal.
Mild to moderate ([**12-27**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior study (tape reviewed) of
[**2106-7-7**], there is no diagnostic change.
.
CXR [**7-13**]:
Compared with [**2106-7-11**], lung volumes have improved and there has
been considerable partial interval clearing of the atelectasis
at the left
base. There is persistent blunting of both costophrenic angles,
left greater than right, consistent with small effusions.
There appears to be slight increase in the upper zone pulmonary
vascularity, consistent with mild CHF.
.
Brief Hospital Course:
# CAD - Cath showed one vessel disease, and Cypher stent was
successfully placed in LAD. The procedure was complicated by
Type A dissection of the LAD, which was stabilized with
successive balloon inflations and placement of 3 mini-vision
(bare metal) stents with subsequent TIMI 2 fast flow. CO/CI
measured at 2.9/2.0. She was on an intraaortic balloon pump to
augment systolic function and on a dopamine drip when she
initially came to the CCU. She was successfully weaned from
dopamine and the IABP was removed. She was transferred to the
floor without any further chest pain or tightness. Patient did
not tolerate the addition of an ace inhibitor or beta blocker
due to low blood pressure, but will continue aspirin, statin and
plavix for further preventive management. Will follow up with
her cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] in the week following
discharge.
.
# Pump - last ECHO on [**2105-6-23**] showed EF of >55%. Repeat ECHO
showed EF of 30-35% and a small to moderately sized pericardial
effusion (see report in results). A second ECHO was obtained
due to persistent hypotension and tachycardia to assess for
possible tamponade, which showed a small effusion and no signs
of tamponade. It was noted that she has a 15-20 mmHg
discrepancy between her thigh and arm BP (thigh 115, arm 95).
The pulsus was normal (4). She had no evidence of end-organ
hypoperfusion.
.
# Rhythm - History of atrial fibrillation, patient has a
[**Company 1543**] DDI pacer. Intermittently paced throughout hospital
stay. Will continue coumadin as an outpatient and will have
follow up with her PCP and in device clinic for further
management.
.
# Pulm - Patient developed pulmonary congestion while she was
admitted. She responded well to Lasix. At the time of
discharge her CXR still showed signs of pulmonary congestion and
small bilateral effusions, but was greatly improved. Her
discharge weight was 53kg and O2 sat was 99% on RA.
.
# FEN - Electrolytes were maintained with K>4 and Mg>2 during
her hospital course. She was continued on heart healthy diet.
.
# Heme - Hematocrit was stable after the cath. She did not
require any additional blood products.
.
# Prophylaxis: Patient was given pneumoboots and heparin for DVT
prophylaxis.
.
# Dispo - PT consult was obtained and she was recommended for
rehab before returning to home.
Medications on Admission:
Oxybutynin 5mg [**Hospital1 **]-
Celexa 5mg daily-
Metoprolol 12.5mg [**Hospital1 **]
Aspirin 81mg daily-
Quinine 325mg prn for leg cramps -
Percocet 5mg prn for arthritis pain-
Vitamins daily-
Lasix 20mg daily-
Oxazepam 15mg qhs prn
Plavix 75mg daily-
Colace 100 mg [**Hospital1 **]
Lipitor 40mg every evening-
Imdur 30mg twice a day-
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Final dose on [**2106-7-14**].
11. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)) as needed for insomnia.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Coronary artery disease
Pericardial effusion
Bilateral pleural effusions
Discharge Condition:
Stable
Discharge Instructions:
breath, chest pain, or dizziness. Limit yourself to less than 2
grams of sodium per day. Do NOT stop your plavix for any
reason. Please weight yourself each day and notify your doctor
of weight gain greater than 3 pounds per day as this may suggest
fluid retention.
Followup Instructions:
Please follow up with your primary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 17753**] within 1 week.
Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] at
[**Telephone/Fax (1) 4105**] within 1 week of discharge.
Completed by:[**2106-7-13**]
ICD9 Codes: 5119, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4509
} | Medical Text: Admission Date: [**2177-1-16**] Discharge Date: [**2177-2-6**]
Date of Birth: [**2125-1-14**] Sex: F
Service: MEDICINE
Allergies:
Darvon
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
bilateral lower extremities arterial ulcers
Major Surgical or Invasive Procedure:
left femoral-popliteal bypass graft angioplasty
History of Present Illness:
52 yof with extensive [**First Name3 (LF) 1106**] history presents to clinic with
concern for infected bilateral lower extremity ulcers. Ms.
[**Known lastname 13257**] is well known to our team and presented today for eval
of her LE ulcers. She recently saw her
pcp who put her on oral steroids. She reports the uclers
worsened and are draining.
Past Medical History:
Type I Diabetes Mellitus
Peripoheral neuropathy
Diabetic Nephropathy (failed transplant)
- pt was scheduled for repeat transplant on [**2174-8-23**] but was
cancelled because of her PVD historybilateral retinopathy s/p
retinal detachment.
Benign Hypertension
significant PVD history with multiple prior LE bypass surgeries
Prior GI bleeding on ASA and plavix
CAD s/p MIx2, s/p LAD stents
s/p CABG [**8-19**]
Meningitis
chronic anemia
- likely multifactorial due to renal failure, hx of antral
erosions and mild esophagitis on EGD
CVA x 2
hyperlipidemia
Social History:
Two children in their 20s. She lives with her boyfriend and has
24-hour support at home from him and from her daughter. She
formerly worked at the post-office. She has a 30-pack-year
history of smoking and quit in [**2165**]. She does not drink
alcohol.
Family History:
Her mother is alive at age 77 without significant medical
problems. [**Name (NI) **] father died at age 76 of sepsis. He also had
type 2 diabetes and prostate cancer. She has a sister age 51
and another sister age 41 who has type 1 diabetes. There is no
family history of blood disorders or colon cancer.
Physical Exam:
On admission:
Vitals: T 94.5-97.2, BP 119-152/40-46, P 58-70, RR 14, O2sat 94%
2L NC
General: lying in bed, no acute distress, appears stated age
HEENT: NCAT, PERLL, anicteric, OP clear
Neck: supple, no LAD
Pulm: poor inspiratory effort, mildly reduced BS at bases,
occasional rhonchi at left base
CV: irreg, appears to have PVCs on A-line [**Location (un) 1131**], nl S1 S2, no
m/r/g
Abd: ecchymoses, soft, overweight, non-tender, +BS
Extrem: both lower extremities wrapped, poor and faint DP/PT
pulses bilaterally, right extremity prior digit amputation
Neuro: CN 2-12 intact, non-focal
Pertinent Results:
admission labs:
[**2177-1-16**] 10:00PM GLUCOSE-219* UREA N-86* CREAT-6.3*#
SODIUM-139 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-23 ANION GAP-25*
[**2177-1-16**] 10:00PM WBC-17.4* RBC-5.51*# HGB-13.8 HCT-48.5*
MCV-88# MCH-25.1*# MCHC-28.5* RDW-20.0*
[**2177-1-16**] 10:00PM PLT COUNT-424
Brief Hospital Course:
The patient was admitted to the [**Year/Month/Day **] Surgical Service for
evaluation and treatment of the ulceration of bilateral lower
extremities. Patient was hemodynamically stable at the time of
admission.
Neuro: The patient received oral and intravenous pain control
with good effect. During the periods when she was mildly
confused or lethargic, the pain medications were used with care.
Patient was alert and oriented until the HD 11 when she was
found to be confused and obtunded in respiratory distress and
subsequently transferred to the ICU. Her mental status has been
fluctuating since.
Psych: Patient has been depressed throughout the entire stay.
She experienced hoplessness and helplessness with her current
situation. She was also voiced wishes to die. Patient has been
seen on by a social work services.
CV: At the time of admission patient was stable from a
cardiovascular standpoint. Few days after the admission she
experienced episodes of nausea. She was rulled out for
myocardial ischemia. Her troponin was elevated in 0.4 range and
in the days to follow, it rose as high as 1.2. Cardiology was
consulted and felt that the etiology was the stress ischemia.
They recommended trending troponins, serial EKGs were done. No
intervention was recommended. There was no acute ischemia.
Recommendation was to stop lisinopril as patient was in
worsening renal failure, beta blocker was recommended, but
currently held, as patient blood pressure has been quite low.
Further follow up was not necessary, perhaps catheterization in
the future. Patient was cleared for the angiogram by cardiology.
Patient had an echocardiogram which showed right ventricular
strain.
Patient had an angiogram done which showed stenosis in the left
femoral to popliteal bypass graft, which was angioplastied.
Patient tolearted the procedure well and was stable
post-procedure. Her signals dopelarable monophasic - posterior
tibialis and dorsalis pedis bilaterally.
Pulmonary: Patient has an underlying COPD. She was initially
stable from the respiratory standpoint. Her oxygen requirement
increased over the course of the week of hodpitalization from
one liter to three liters on nasal canula. As her renal function
worsened she developed bilateral pleural effusion, worse on the
right. She was found with altered mental status on HD 11. Her ph
at that time was 7. She was emergently intubated and transferred
to the ICU. She remained intubated for a day and extubated
easily. She underwent diagnostic/therapeutic thoracocentesis on
HD 12 while in ICU. She also recieved more agressive
hemodialysis to optimaize her respiratory status. After transfer
from the ICU to floor her repiratory status remained stable,
sating over 92% on 3L NC.
GI/GU/FEN: Patient's intake and output were closely monitored.
She is on hemodialysis and continued to be hemodialysed on MWF
per her schedule. However, she was also hemodilaysed on three
consecutive days following the respiratory distress which was
most likely attributable to right heart failure and fluid
overload. Electrolytes were routinely followed, and were not
replaced as patient is on hemodialysis. Patient was on regular
diet, however has had a poor intake. No supplemental nutrition
was provided.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her WBC remoned high
despite the treatment with levofloxacin and unasyn. Levofloxacin
was stopped on HD 12, the dose of unasyn was decreased on HD14.
Patient has remained afebrile. Patient has blood cultures
pending.
Wound care was provided twice daily to lower extremitied
bilaterally. The wounds are significantly improved bilaterally.
The culture grew beta streptococcus.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. Patient was
followed by [**Last Name (un) **].
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin, aspirin
and plavix. She was unable to umbulate secondary to her painful
feet. She ambulated to chair.
At the time of transfer, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, yet had poor intake. She was stable from respiratory and
cardiovascular standpoint. Her code status was not addressed,
she is full code at the time of transfer.
.
.
ICU course: The patient was transferred to the MICU for GI
bleed. This stabilized shortly after ICU admission, with no
further signs of bleeding per rectum. However, she developed a
supraventricular arrhythma with HR 130-140, similar to episodes
of junctional tachycardia documented during prior admissions.
EKG while tachycardic also demonstrated ischemic ST elevations
in the inferior leads with reciprocal depressions in the
precordium. Goals of care were clarified with the patient and
her family, and the decision was made not to pursue aggressive
cardiac interventions including cathetherization, CPR, shocks,
or intubation. Shortly thereafter, the patient's blood pressure
became unstable, requiring >8L of fluid as well as
neosynephrine. She then spontaneously converted to NSR and her
BP stabilized, although pressors continued to be required.
Goals of care were again addressed with the patient and her
family. The decision was made to move toward making the patient
comfortable. Appropriate medication changes were made, and the
patient died the following day.
Medications on Admission:
lipitor 40mg once daily, nephrocaps 1 tab daily, calcium acetate
667 2tabs [**Hospital1 **], plavix 75mg daily, tricor 145mg daily, lantus 12u
am , humalog ss, lisinopril 20 mg daily, lorazepam 1mg qhs,
metop succinate 100mg daily, faroxetine 10mg daily, tylenol prn,
vit c 500mg daily, asa, zinc 50 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2177-2-6**]
ICD9 Codes: 5856, 5849, 5119, 4280, 3572, 2724, 496, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4510
} | Medical Text: Admission Date: [**2113-11-16**] Discharge Date: [**2113-11-19**]
Date of Birth: [**2058-7-24**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Chest pain. Descending aortic dissection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year-old with PMHx only remarkable for HTN presents as
transfer from OSH with reports of descending aortic dissection.
The patient describes that he woke up this morning with mid-back
pain that wrapped around his to his chest. He had extreme chest
tightness and pain - he never had an episode like this before.
The patient went to the ED at a local hospital where his BP was
found to be 220s/110s. The patient's pressure was brought down
with beta-blockers. A CTA of his torso was obtained and showed [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 11916**] Type B aortic dissection. The patient was started on a
labetalol gtt and transferred to [**Hospital1 18**]. On arrival, the patient
reports no headaches, no nausea, no vomiting. He reports that
the pain in his chest and back resolved after some dilaudid and
once his blood pressure came down. He reports no abdominal pain
and no leg pain.
Past Medical History:
HTN, COPD
Social History:
positive for tobacco and ETOH use
Family History:
Non-contributory
Physical Exam:
VS: 97.4 BP R arm 121/73 BP L arm 113/70 HR 66 RR 16 96%2L
GEN: NAD, A&Ox3
HEENT: No scleral icterus
NECK: Supple, no bruits
CV: RRR, nl S1 and S2, no m/r/g
LUNGS: Clear B/L
ABD: soft, NT, ND, no hernias, no masses
EXT: no c/c/e of LE
VASC:
Radial Fem [**Doctor Last Name **] DP PT
R 2+ 2+ 2+ D 2+
L 2+ 2+ 2+ D 2+
Pertinent Results:
[**2113-11-16**] 07:45PM GLUCOSE-192* UREA N-18 CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
[**2113-11-16**] 07:45PM cTropnT-<0.01
[**2113-11-16**] 07:45PM WBC-11.5* RBC-4.63 HGB-15.9 HCT-44.8 MCV-97
MCH-34.4* MCHC-35.5* RDW-13.6
[**2113-11-16**] 07:45PM PLT COUNT-184
Brief Hospital Course:
The patient was admitted under Dr.[**Name (NI) 1720**] service on [**2113-11-16**].
He was observed overnight in the ICU and kept on a labetalol gtt
to keep SBP between 100 and 130.
On [**2113-11-17**] (HD2), the patient was evaluated by Dr. [**Last Name (STitle) 914**]
from CT surgery. He also recommended that the patient's
dissection to be controlled with BP medications (conservative
treatment) and that no surgical intervention was needed. The
patient was then started on an oral beta-blocker regimen and
transferred to the VICU.
On HD3, a repeat CTA was obtained that showed no progression of
the dissection.
On HD4, the patient maintained an SBP less than 140 on his po
regimen of labetalol. He denied any more chest pain. He was
given instructions on how to stop smoking and to make sure that
he get his blood pressure checked on a regular basis, as he does
not have a regular PCP. [**Name10 (NameIs) **] was instructed to get his blood
pressure checked 4-5 times a week at a local drug
store/pharmacy. He agreed to these conditions and he was deemed
stable for discharge home.
Medications on Admission:
None
Discharge Medications:
Nicotine patch 14 mg TD q day
Labetalol 200 mg po bid
Discharge Disposition:
Home
Discharge Diagnosis:
Type B aortic dissection
Discharge Condition:
Good
Discharge Instructions:
Until you have established a PCP, [**Name10 (NameIs) **] get your blood pressure
checked 4 to 5 times a week at a local drug store/pharmacy. If
your systolic blood pressure is above 140, go to a local
Emergency Department to have your blood pressure brought down.
Please explain to them your condition (aortic dissection)
beforehand.
Please go to an Emergency Department as soon as possible if you
experience chest pain, severe headaches, nausea, vomiting, or
profuse sweating.
Followup Instructions:
Call Dr.[**Name (NI) 1720**] office on [**2113-11-20**] to schedule follow-up CTA
(to be done in one months time) and follow-up appointment with
Dr. [**Last Name (STitle) **]. His office number is ([**Telephone/Fax (1) 2867**].
Please set-up a PCP to keep [**Name Initial (PRE) **] close eye on your blood pressure.
Until you have established a PCP, [**Name10 (NameIs) **] get your blood pressure
checked 4 to 5 times a week at a local drug store/pharmacy. If
your systolic blood pressure is above 140, go to a local
Emergency Department to have your blood pressure brought down.
Please explain to them your condition (aortic dissection)
beforehand.
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4511
} | Medical Text: Admission Date: [**2153-4-6**] Discharge Date: [**2153-4-10**]
Date of Birth: [**2097-12-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain, positive exercise tolerance test
Major Surgical or Invasive Procedure:
Cardiac catherization with 2 stents (DES) placed to right
coronary artery.
History of Present Illness:
This is a 55-year-old woman with DM II, HTN, hyperlipidemia and
an extensive family history of early CAD who is admitted on [**4-6**]
after anginal symptoms during outpatient ETT and EKG changes
suggestive of myocardial ischemia.
.
Ms. [**Known lastname 24850**] complains of 4 months of exertional chest pain.
She is aware of a "pressure" in her chest after about 10 minutes
of exercise (such as walking up stairs). It is associated with
some mild SOB and palpitations; she [**Known lastname **] nausea, vomiting, or
diaphoresis. Prescribed nitro by outpatient provider.
.
On admission, Ms. [**First Name (Titles) 24851**] [**Last Name (Titles) **] chest pain, shortness of
breath, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Other review of systems is
negative for abdominal pain, constipation, fever, chills, or
other concerning signs or symptoms. Ms. [**Known lastname 24850**] does
complain of a headache, which she states is her usual migraine.
Past Medical History:
--DM II
--Dyslipidemia
--Hypertension
--Anxiety
--Migraines
--Osteoporosis
--Iron deficiency anemia
Social History:
Originally from [**Male First Name (un) 1056**]. Lives with uncle. [**Name (NI) **] 5 children
ranging in age from 42 to 34. [**Name (NI) 4273**] tobacco, ETOH, or other
drug use.
Family History:
Brothers died at 60 and 65 of MI. Mother died at 57 of MI.
Sister died at 56 of MI. Father died at 80 of MI. Multiple
family members with DM II and hypertension. No family history
of cancer.
Physical Exam:
VS: T 98.0 BP 154/66, HR 75 RR 16 O2 sat 100% RA, blood sugar
135
GENERAL: Pleasant woman, appears stated age, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVP not elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Midline scar from
tubal ligation surgery.
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+, Radial 2+, Popliteal 2+
Left: Carotid 2+, Radial 2+, Popliteal 2+
Pertinent Results:
[**2153-4-6**] 09:55PM GLUCOSE-256* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-31 ANION GAP-15
[**2153-4-6**] 09:55PM estGFR-Using this
[**2153-4-6**] 09:55PM CK(CPK)-58
[**2153-4-6**] 09:55PM CK-MB-NotDone cTropnT-<0.01
[**2153-4-6**] 09:55PM CALCIUM-10.2 PHOSPHATE-4.5 MAGNESIUM-1.6
[**2153-4-6**] 09:55PM WBC-6.6 RBC-4.45 HGB-12.8 HCT-39.2 MCV-88
MCH-28.7 MCHC-32.6 RDW-13.1
[**2153-4-6**] 09:55PM PLT COUNT-301
[**2153-4-6**] 09:55PM PT-12.2 PTT-24.1 INR(PT)-1.0
.
EKG: T wave inversions in V1-V5. ST depressions in I and II.
.
ETT [**2153-4-6**]:
Ms [**Known lastname 24850**] is a 55 year old woman with history of
hyperlipidemia, diabetes, hypertension who presents with typical
angina
for several months. She completed 4 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**]
protocol
representing a poor exercise tolerance for her age; ~ 2.8 METs.
The
test was stopped due to fatigue. She complained of substernal
chest
pain ([**7-5**]) 2 minutes into exercise that peaked at 7/10 which
resolved 5
minutes into recovery. There were 0.[**Street Address(2) 20505**] depression at
peak
exercise which resolved upon rest. During recovery she had T
wave
inversions starting from 2 minutes in recovery to 7 minutes in
recovery.
She had a run of atrial tachycardia 2 minutes into recovery
lasting for
6 beats. The rhythm was sinus. The patient was hypertensive at
baseline
however had appropriate hemodynamic response to exercise.
IMPRESSION: Anginal symptoms at low workload with ST changes
suggestive
of myocardial ischemia. Nuclear report sent separately.
.
Nuclear stress [**4-6**]:
Probably normal myocardial perfusion at level of exercise
achieved with mild fixed apicoanterior and apical defect which
is commonly seen with our current camera. However, given the
stress results an LAD distribution lesion can not be excluded.
.
Cath [**4-9**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated
single vessel CAD. The LMCA had no angiographically apparent
CAD. The
LAD had a 50% stenosis in the mid vessel. The LCx had no
angiographically apparent CAD. The RCA had a proximal 50%
stenosis and a
distal 70% stenosis.
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension with an SBP of 154 mmHg.
3. Successful PTCA and placement of a 2.5x12mm Promus drug
eluting stent
in the mid RCA and a 2.5x12mm Promus drug eluting stent in the
proximal
RCA. Final angiography showed normal flow, no apparent
dissection, and
no residual stenoses. (See PTCA comments.)
4. The right common femoral arteriotomy was successfully closed
using a
6 Fr Angioseal VIP device.
.
FINAL DIAGNOSIS:
1. Single vessel CAD.
2. Successful placement of DES to RCA.
Brief Hospital Course:
This is a 55-year-old woman with a past medical history of DM
II, HTN, hyperlipidemia, and a strong family history of CAD who
was admitted to [**Hospital1 18**] after an ETT suggestive of myocardial
ischemia. Patient underwent cardiac catherization on [**4-9**] and
had 2 DES placed to RCA.
CAD: Patient has multiple risk factors for CAD including HTN,
hyperlipidemia, DM II, and a strong family history of heart
disease. An ETT on [**4-6**] was suggestive of myocardial ischemia.
Patient underwent cardiac catherization (via right groin) on
[**4-9**] without complications. Two DES were placed to RCA. Ms.
[**Known lastname 24850**] was maintained on home lisinopril 10mg qd and started
on Plavix, Toprol 25mg qd, Simvastatin 40mg qd, and ASA 325mg
qd. She was maintained on telemetry and monitored with serial
EKGs. Last HgbA1C is 7.9--patient is on 3 oral hypoglycemics as
an outpatient, but may be switched to insulin by primary
provider. (Dr. [**Last Name (STitle) **], patient's PCP, [**Name10 (NameIs) **] been notified of
patient admission and elevated HgbA1C). Patient will follow-up
with Dr.[**Name (NI) 3733**] in cardiology clinic on [**4-17**].
.
ASPIRIN DESENSITIZATION: Patient with known allergy to aspirin
including shortness of breath, chest pain, and diaphoresis. Ms.
[**Known lastname 24850**] was successfully desensitized to aspirin in CCU on
[**4-8**] via ASA desensitization protocol. She should continue
taking aspirin daily; if she fails to do so, her allergy may
return.
.
DIABETES: Patient with DM II for the last ~20 years not ideally
controlled on 3 oral agents. (Last HgbA1C is 7.9). During this
admission she was started on glargine and an insulin sliding
scale. Ms. [**Known lastname 24850**] will be discharged on her home
hypoglycemics, but her PCP may decide to switch to insulin for
superior control. Dr. [**Last Name (STitle) **] is in agreement with this plan.
.
HYPERLIPIDEMIA: Patient was discharged on Simvastatin 40mg QD.
.
HYPERTENSION: Patient was maintained on home ACE-I and started
on Toprol 25mgQD.
.
ANXIETY: Patient with baseline anxiety, exacerbated by hospital
stay. Patient was seen by social work consult, and may benefit
from counseling as an outpatient.
.
CHRONIC BACK PAIN, NEUROPATHY: Nortryptaline was continued.
Medications on Admission:
Glimepiride 4 mg Tablet
Lisinopril 10 mg Tablet
Lovastatin 40 mg Tablet
Metformin 1,000 mg Tablet
Nitroglycerin 0.4 mg Tablet, Sublingual
Nortriptyline 10 mg Capsule
Pioglitazone [Actos] 45 mg Tablet
Propoxyphene N-Acetaminophen 100 mg-650 mg Tablet TID prn
Omeprazole
Discharge Medications:
1. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take one tablet as needed for chest pain for up to 3 tablets in
15 minutes. Call your doctor if you take more than one tablet,
and call 911 if you take 3 tablets.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Do not take until evening of [**4-11**].
10. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO three times a day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Coronary artery disease
2. Stable angina
3. Abnormal exercise tolerance test
.
Secondary
1. DM II
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms. [**Known lastname 24850**],
It was a pleasure taking care of you on this admission. You
were admitted to the hospital because of an exercise tolerance
test (stress test), which showed some damaged heart muscle. You
had a cardiac catherization on [**4-9**] and 2 DES (drug eluding
stents) were placed into your right coronary artery. IT IS VERY
IMPORTANT THAT YOU TAKE A MEDICATION CALLED PLAVIX (CLOPIDOGREL)
UNTIL INSTRUCTED OTHERWISE BY YOUR DOCTOR.
.
You also underwent a procedure during which we "desensitized"
you to aspirin. You can now take aspirin without having an
allergy to this medication. It is very important that you take
aspirin every day or else your allergy may return.
.
The following changes were made to your medications:
1. START Plavix (Clopidogrel) 75mg once a day
2. START Aspirin 325mg once a day
3. START Toprol XL 25mg once a day
4. STOP taking omeprazole
5. START Ranitidine 150mg once a day
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
Return to the hospital if you develop chest pain, shortness of
breath, severe headache, palpitations, nausea, vomiting,
diarrhea, bleeding in your urine or stools, fevers, chills, or
other concerning signs or symptoms.
Followup Instructions:
[**2153-4-17**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) 2352**]
[**Location (un) **] ([**Location (un) 2352**], MA), [**Location (un) **]
[**Location (un) 2352**] - ADULT MEDICINE (SB)
[**2153-4-17**] 04:00p [**Doctor Last Name **]-CC7
[**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
ICD9 Codes: 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4512
} | Medical Text: Admission Date: [**2137-12-3**] Discharge Date: [**2137-12-10**]
Date of Birth: [**2067-2-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2137-12-3**] Repair of abdominal aortic aneurysm with 16-mm
Dacron tube graft.
History of Present Illness:
This 70-year-old gentleman has a 6 cm aneurysm
of the infrarenal aorta with a very short proximal neck and
heavily calcified iliac arteries. The proximal attachment
site was unsuitable for endovascular repair.
Past Medical History:
CAD (s/p LCx stent '[**30**]), Cardiomyopathy (improved EF 45%
recently), Chol, Arthritis, NIDDM, GERD
Social History:
remote smoker
denies alcohol
Family History:
non contributary
Physical Exam:
AFVSS
a/o nad
grossly intact
supple / farom
neg lymphandopathy
neg thyroidmegaly
neg carotid bruits
cta
rrr
pos bs / left cva tendernes - to note over surgical scar / neg
right cva tenderness, surgical scar with staples, minimal
seroussang drainage, hematoma noted
palp fems b/l
palp distal pulses b/l
Pertinent Results:
[**2137-12-9**] 03:00AM BLOOD
WBC-7.1 RBC-3.18* Hgb-10.5* Hct-29.5* MCV-93 MCH-32.9*
MCHC-35.4* RDW-13.8 Plt Ct-236
[**2137-12-5**] 04:00AM BLOOD
PT-15.2* PTT-33.6 INR(PT)-1.3*
[**2137-12-9**] 03:00AM BLOOD
Glucose-119* UreaN-11 Creat-0.5 Na-139 K-3.4 Cl-104 HCO3-25
AnGap-13
[**2137-12-10**] 05:45AM BLOOD
Calcium-8.2* Mg-2.0
[**2137-12-8**] 12:55 pm STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2137-12-9**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference
Range-Negative).
[**2137-12-6**] 12:47 PM
CHEST (PORTABLE AP)
REASON FOR EXAM: Assess triple-lumen catheter.
Comparison is made with prior study performed a day earlier.
Right IJ line tip is in the superior right atrium. Left
transvenous pacemaker lead terminates in standard position in
the right ventricle. NG tube tip is in the stomach. There is no
pneumothorax. Bibasilar atelectasis, greater on the left side
are stable. The left CP angle was not included on this film. If
any, there is a small left pleural effusion.
Brief Hospital Course:
Mr. [**Known lastname 542**],[**Known firstname **] [**Numeric Identifier 75821**] was admitted on [**2137-12-3**] with AAA. He
agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a Repair of abdominal
aortic aneurysm with 16-mm Dacron tube graft.
.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the CVICU
for further stabilization and monitoring. He was weaned from
pressure support, he was extubated.
He was then transferred to the [**Date Range **] for further recovery. While
in the [**Date Range **] he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status
To note while in the [**Name (NI) **] pt developed an illeus. He recieved an
NG tube. He was kept NPO for a number of days. Pt did have BM
immediatly post - operative period. A GS consult was obtained.
They performed a flex sig. There was no sign of ischemic
colitis. Once it pt experienced flatus anf minimal drainage from
the NG tube. The NG tube was removed. Pt diet was advanced. ON
DC pt is eating a normal diet.
Pt also had Anemia secondary to blood loss form the OR
procedure. He recieved a total three units PRRBC. This helped
his pressure. ON Dc is HCt is stable.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with VNA in stable
condition.
Medications on Admission:
Meds: ASA 325', Captopril 12.5'', Celexa 40', Levoxyl ?,
Metformin 500'', Lopressor 25'', Niaspan, Vytorin [**8-/2110**]', Pletal
100''
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
5. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. [**Last Name (un) 1724**]
Meds: ASA 325', Captopril 12.5'', Celexa 40', Levoxyl ?,
Metformin 500'', Lopressor 25'', Niaspan, Vytorin [**8-/2110**]', Pletal
100''
13. Niaspan 500 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**], [**Location (un) 55**]
Discharge Diagnosis:
AAA
Anemia secondary to blod loss form OR / tranfused 3 units PRBC
Illeus post perative period / requiring NG tube
CAD (s/p LCx stent '[**30**])
Cardiomyopathy (improved EF 45% recently)
Chol
Arthritis
NIDDM
S/P AICD pacer
S/P C4/5 fusion
S/Psubtotal thyroidectomy
GERD
Discharge Condition:
STABLE
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-4**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-29**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] please call his assistant [**Doctor First Name 25812**] at
([**Telephone/Fax (1) 18181**] for a FU appointment in 1 weeks. [**Last Name (un) 20220**] should
have had an appointment scheduled next week.
You should make an appointment for follow-up with your PCP upon
discharge
Completed by:[**2137-12-10**]
ICD9 Codes: 2851, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4513
} | Medical Text: Admission Date: [**2183-8-2**] Discharge Date: [**2183-8-3**]
Date of Birth: [**2159-5-7**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
DKA and abdominal pain
Major Surgical or Invasive Procedure:
pelvic ultrasound
History of Present Illness:
24 yo F with type 1 diabetes and pelvic pain/bleeding who
presents with diabetes ketoacidosis.
.
Patient woke up this morning with menorrhagia and left sided
pelvic pain. Her blood sugar was 200s upon waking up. She took
12u novolog and her blood sugar at noon was in 400s and decided
to come to ED
.
Patient reports soaking through 4 sanitary pads already so far.
She also claims that there is clot. Her LMP was [**3-3**] and she has
been seeing a gynecologist at [**Hospital1 112**]. She does not know what her
diagnosis is as of yet. SHe also complains of [**10-7**] sharp LLQ
pain that does not radiate. She denies nausea/vomiting/diarrhea.
SHe claims that she has rupturing of ovarian cyst w/ LLQ pain
for the past year but this feels more tender than usual. SHe
takes percocet at home for the pain.
.
Other than that, she denies chest pain, SOB, cough, sinus
tenderness, N/V/D, headahce, photosensitivity, dizziness,
myalgia. She admits to polyuria today. She has had multiple UTIs
in the past, with presenting symtpoms as back pain which she
denies today. SHe finished 7d course of Bactrim day prior to
admission. She claims to be compliant to insulin. Denies new
medication.
.
She presented to the ED with FS 400s. Her initial vitals were
T98 P115 BP129/74 R24 99% on RA. ON presentation, she was weak
and cannot speak. Patient received 3L of NS and 1L D5NS w/ 40
KCL. Her urine HCG was negative. She also received 4mg Morphine
for pelvic pain. Pelvic exam show brown, red blood in vaginal
vault, left adnexal tenderness but no cervical motion
tenderness. Pelvic ultrasound show normal ovaries and small
amount of free fluid. She has no WBC, afebrile and urine is
negative.
Past Medical History:
- type 1 DM diagnosed 4 years ago. Has had a few DKA, followed
by Dr. [**Last Name (STitle) **] at [**Last Name (un) **]
- endometriosis s/p ??D & C [**5-3**]
- irregular menses(seen by Dr. [**Last Name (STitle) **] at [**Hospital1 756**])
- celiac sprue: no diarrhea if she avoids gluten
- ruptured ovarian cyst
Social History:
She works as hair dresser. She currently lives with family.
DEnies smoking/ETOH/drug.
Family History:
uncle has diabetes
Physical Exam:
T98.4 BP102/65 P90 99% on RA
Gen- pleasant female in no acute distress
HEENT- anicteric, PERRLA, EOMI, no sinus tenderness, mmm, neck
supple, no cervical [**Doctor First Name **]
CV- rrr, no r/m/g
resp- CTAB
abdomen- soft, tender in left flank, no rebound/guarding, soft,
no hepatosplenomegaly, nml bowel sound
Ext- no edema, strong pedal pulses
Pertinent Results:
[**2183-8-2**] 12:43PM WBC-7.9 RBC-4.66 HGB-13.9 HCT-41.0 MCV-88
MCH-29.8 MCHC-33.8 RDW-13.7
[**2183-8-2**] 12:43PM NEUTS-71.0* LYMPHS-23.8 MONOS-2.3 EOS-1.0
BASOS-1.9
[**2183-8-2**] 12:43PM GLUCOSE-521* UREA N-13 CREAT-0.7 SODIUM-130*
POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-10* ANION GAP-30*
[**2183-8-2**] 12:45PM GLUCOSE-474* LACTATE-1.4 NA+-135 K+-4.3
CL--97* TCO2-14*
[**2183-8-2**] 04:00PM ALBUMIN-4.2 CALCIUM-7.7* PHOSPHATE-1.4*
MAGNESIUM-1.7
[**2183-8-2**] 04:00PM LIPASE-38
[**2183-8-2**] 04:00PM ALT(SGPT)-17 AST(SGOT)-13 ALK PHOS-106
AMYLASE-35 TOT BILI-0.3
[**2183-8-2**] 04:00PM GLUCOSE-137* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-13* ANION GAP-18
[**2183-8-2**] 04:09PM GLUCOSE-132* LACTATE-2.0 NA+-141 K+-3.4*
CL--112 TCO2-14*
[**2183-8-2**] 09:35PM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-1.7
[**2183-8-2**] 09:35PM GLUCOSE-197* UREA N-6 CREAT-0.5 SODIUM-140
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-18* ANION GAP-14
[**2183-8-2**] 12:00PM URINE RBC-[**11-17**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-[**6-7**]
[**2183-8-2**] 12:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2183-8-2**] 12:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033
Pelvic and Transvaginal Ultrasound [**8-2**] - Transabdominal
ultrasound of the pelvis demonstrates a uterus measuring 6.6 x
3.9 x 0.9 cm. Vaginal examination was performed for better
evaluation of the endometrium and adnexa. The endometrium
measures 6 mm in thickness. The right ovary is normal in size
measuring 3.0 x 1.3 x 1.3 cm. The right ovary demonstrates
normal waveform and flow. The left ovary is normal in size and
measures 1.9 x 1.3 x 1.6 cm. There is normal flow and waveform
within the left ovary. Normal follicular activity is
demonstrated bilaterally. There is a small amount of free
fluid. There is no evidence of hydronephrosis within the
kidneys. There is a tiny 8-mm simple-appearing renal cyst
within the right kidney.
Brief Hospital Course:
24yo F w/ type 1 diabetes, endometrisis, frequent ruptured
ovarian cyst, presents with DKA and abdominal pain [**1-30**] ruptured
ovarian cyst.
1) DKA: pt with initial gap 26, no WBC, UA negative for nit and
LE with few bacteria, pelvic ultrasound show nml appearing
ovaries w/ small amt of fluid, nml Cr,lactate 2, claimed to be
compliant to medication. Was started on insulin gtt, given IVF
with K/Phos repletion. The anion gap closed within 6 hours and
the pt was given SQ Lantus 32 U (her home dose of insulin) and
began to take po. Her insulin gtt was d/c'd 3 hours later.
Frequent electrolyte checks overnight during hospital course
were performed to confirm that the pt did not open her anion gap
again. She was placed on her home insulin regimen of Lantus 32 U
and Novolog 10 U before meals with sliding scale with good
result. At the time of discharge, it was unclear what
precipitated DKA. The pt describes UTIs as having been prior
triggers for DKA in the past and she did report h/o finishing 7
day course of Bactrim for UTI prior to admission. The pt also
p/w abd pain and menorrhagia [**1-30**] ruptured ovarian cyst; however
DKA can also contribute to abdominal pain. It is questionable if
pain from ruptured ovarian cyst may be a stress trigger for DKA,
however pt does report history of elevated blood sugars with
ruptured ovarian cysts. At the time of discharge, her urine
culture was still pending. We will f/u the results of her urine
cx and will contact the pt if there is a need to initiate
antibiotic tx for UTI. There was no need for CXR during this
admission as the pt remained afebrile with no WBC and lungs were
clear on physical exam.
.
2) menorrhagia and pelvic pain: urine HCG negative; pelvic
ultrasound significant for small amt of free fluid, possible
ruptured ovarian cyst per ob/gyn in ED. The pt was given
morphine and percocet for pain control with good result. A gyn
consult was not obtained in house as the pt remained stable with
improving abdominal pain. She will follow up with Dr. [**Last Name (STitle) **]
at [**Hospital1 112**] for her further gyn care.
.
3) hyponatremia: Likely from hyperglycemia and dehydration;
resolved during hospital course.
.
4) nongap metabolic acidosis: Likely from NS, HCO3 continued to
trend upwards during hospital course.
.
5) PPx- There was no need for PPI on this admission. The pt
ambulated freely. We continued Macrobid for UTI ppx.
.
6) FEN- gluten free, diabetic diet. repleted lytes as necessary.
.
7) code- full
.
8) dispo- The pt was discharged home in good condition as DKA
and abdominal pain resolved. She was given instructions to f/u c
f/u urine cxs, if positive, will contact pt and prescribe course
of antibiotics.
Medications on Admission:
insulin(novolog 10u before meal and 32u lantus)
reglan 10 QID
macrobid 50mg [**Hospital1 **]
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32)
Units Subcutaneous at bedtime.
Disp:*3 100* Refills:*2*
2. Humalog 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
before meals: Please combine this with the sliding scale insulin
Disp:*1 100* Refills:*2*
3. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Left Ruptured Ovarian Cyst
Discharge Condition:
Good.
Discharge Instructions:
Please take all of your medication listed as instructed below.
In particular, please take your insulin regularly. Lantus 32
units every night and Humalog 10 units before each meal with a
sliding scale.
We will follow up with you regarding your urine culture results.
If they are positive, we will call you and give you specific
instructions on what antibiotics you should take and for how
long.
Followup Instructions:
Please follow up with your primary care provider and your [**Name9 (PRE) **]
doctor, Dr. [**Last Name (STitle) **], within 1 week of your hospitalization. Please
follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 756**] for your gynecological
care.
Completed by:[**2183-8-3**]
ICD9 Codes: 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4514
} | Medical Text: Admission Date: [**2160-2-12**] Discharge Date: [**2160-3-7**]
Date of Birth: [**2086-12-13**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
Abdominal Pain; Small bowel obstruction
Major Surgical or Invasive Procedure:
Placement of PICC line with interventional radiology ([**2160-2-13**]).
Percutaneous drainage of pelvic fluid collection with pigtail
drain placement ([**2160-2-15**]).
History of Present Illness:
Mr. [**Known lastname **] is a 73 y/o M with bladder cancer who recently
underwent radical cystoprostatectomy with ileal loop urinary
diversion. Prior to that, he also underwent an endovascular
repair of a 5.3-cm abdominal aortic aneurysm found during his
pre-op workup. His post op course was significant for a
post-operative ileus, which required replacement of his
nasogastric tube. His ileus recovered and he had been doing
well until he noted increasing abdominal distention and
discomfort on Sunday ([**2-10**]) night, which became severe to the
point where he dialed 911 to be taken to the hospital. He also
noted having fluctuating temperatures up to 102. His CT abdomen
and pelvis from the OSH showed multiple dilated loops of small
bowel with question of "high grade, possibly partial SBO". He
was transferred to [**Hospital1 18**] for continued management.
Past Medical History:
PMH: bladder tumor, benign prostatic hypertrophy, history of MI
in [**2136**], hypertension, and abdominal aortic aneurysm.
PSH:
coronary angioplasty [**2136**]
CABG x 4 [**2151**]
Cystoscopy and transurethral resection of bladder tumor and he
has undergone BCG treatment for his history of bladder cancer.
Social History:
Denies tobacco, etoh or illicit drug use
Family History:
CAD and Ruptured aortic aneurysm in his brother
Pertinent Results:
[**2160-3-7**] 08:43AM BLOOD WBC-6.3 RBC-3.52* Hgb-10.0* Hct-30.9*
MCV-88 MCH-28.4 MCHC-32.4 RDW-17.1* Plt Ct-201
[**2160-3-6**] 05:18AM BLOOD WBC-7.2 RBC-3.39* Hgb-9.8* Hct-29.1*
MCV-86 MCH-28.9 MCHC-33.6 RDW-17.0* Plt Ct-225
[**2160-3-5**] 06:07AM BLOOD WBC-6.9 RBC-2.95* Hgb-8.3* Hct-25.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-17.2* Plt Ct-263
[**2160-3-7**] 08:43AM BLOOD Glucose-133* UreaN-14 Creat-0.7 Na-139
K-3.5 Cl-103 HCO3-28 AnGap-12
[**2160-3-7**] 08:43AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.1
Brief Hospital Course:
Patient was admitted to Urology service on [**2160-2-12**] from an OSH
with a small bowel obstruction. He already had an NGT in place
to low wall suction which was continued upon admission. His
imaging studies from the OSH were carefully reviewed with [**Hospital1 18**]
radiology and by both the urology team as well as the general
surgery team. He felt that his abdominal discomfort had
somewhat improved after placement of the NGT. A general surgery
consult was requested and recommendations included placement of
PICC line and institution of total parenteral nutrition, given
his poor nutritional status and poor oral intake since his
operation. A PICC line was placed by interventional radiology
and TPN was started on [**2160-2-13**]. He underwent a repeat abdominal
x-ray series, which showed some passage of oral contrast from
his OSH CT scan into the large bowel. Upon re-review of his CT
scan, there was some concern for a possible organizing pelvic
fluid collection concerning for early abscess. On [**2160-2-15**], he
underwent a repeat CT scan of the abdomen and pelvis with oral
and IV contrast in order to look for any progression of the
pelvic fluid collection and evaluate for possible drainage.
After the CT scan was reviewed, the patient underwent
percutaneous drainage and pigtail drain placement to drain his
pelvic fluid collection. The fluid aspirated was sent for
culture and other fluid studies to determine the origin of the
fluid.
Mr. [**Known lastname **] also appeared to be somewhat discouraged and withdrawn,
for which, a social work consult was requested on [**2160-2-14**] for
evaluation for possible situational depression and consideration
of possible therapeutic interventions versus emotional support.
On [**2160-2-19**], pt. was taken to the OR for exploratory laparotomy
and abscess drainage. Post op, he was transferred to the [**Hospital Ward Name 332**]
ICU intubated and sedated. He was extubated on [**2160-2-20**] without
complication, and currently weaning off oxygen on [**2-20**]. As his
SBO was thought to be due to fluid collections compressing the
bowel, SBO was being monitored post-operatively with plan to
restart the patient's po home meds once resolved. He was kept
strict NPO, with NGT to low wall suction; his TPN was restarted
on the morning of [**2-20**]. Continuing treatment with meropenem and
linezolid, and monitoring with daily surveillance cultures per
infectious disease recommendations. He was deemed medically
stable for call out to the medical floor on [**2160-2-20**]. Final
cultures showed were pertinent for VRE and his antibiotic course
was changed to Linezolid, Ciprofloxacin and Flagyl. A penrose
drain was kept in place for drainage of pelvic abcess, NGT was
retained until the passage of flatus, with the passage of flatus
his diet was very slowly advanced his antibiotics were oralized.
His HCT drifted downward on two occasions to 23 and 25
respectively, he was transfused 2 units each time with
appropriate responses in his HCT. To help stimulate his appetite
he was started on a short course of megase. On HD 25 he was
discharged to Cape [**Hospital **] Rehabilitation Center, he was in
stable condition, ambulating independently tolerating a regular
diet. He required TID changes of wicking material at previous
penrose site and continuation of oral abx until [**2160-3-8**].
He and his family was advised to follow up with all other health
care providers after such a prolonged hospital course. He is
advised to contact Dr.[**Name (NI) 84174**] office to arrange follow up
following discharge from rehab.
Medications on Admission:
AMITRIPTYLINE 40 mg once a day
AMLODIPINE 2.5 mg once a day
CARVEDILOL 3.125 mg twice a day
DOXAZOSIN 2 mg once a day
EZETIMIBE-SIMVASTATIN [VYTORIN [**9-/2130**]] once a day
ISOSORBIDE MONONITRATE 30 mg once a day
FAMOTIDINE 40 MG [**Hospital1 **]
OXYCODONE-ACETAMINOPHEN 5 mg-325 mg [**12-22**] Tablet(s) prn
PENTOSAN POLYSULFATE SODIUM [ELMIRON] 100 mg three times a day
ASPIRIN 325 mg once a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain; fever >100.5.
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1.5 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1.5 days.
Disp:*3 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 1.5 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Small Bowel Obstruction and pelvic abcess
Discharge Condition:
Stable
Discharge Instructions:
-Please resume all home meds
-Tylenol can be used for pain
-You may shower, but do not immerse incision, no tub
baths/swimming
-Small white steri-strips bandages will fall off in [**4-25**] days,
you may remove at that time if irritating
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incisions, call your doctor or
go to the nearest ER
Followup Instructions:
Please contact Dr.[**Name (NI) 19910**] office to arrange a follow up
appointment.
Please follow up with both your PCP and Cardiologist after your
rehabilitation stay to review meds and lab work.
Completed by:[**2160-3-7**]
ICD9 Codes: 0389, 5990, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4515
} | Medical Text: Admission Date: [**2113-2-28**] Discharge Date: [**2113-3-9**]
Date of Birth: [**2041-4-26**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Methotrexate / Aspirin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
minimally invasive esophagectomy with gastric pull-up
History of Present Illness:
Mr. [**Known lastname 25006**] is a 71 yo M who had an EGD done in [**10-10**] for
abdominal pain with weight loss. This demonstrated an esophageal
mass. Biopsy demonstrated poorly differentiated adenocarcinoma.
T3 lesion on EUS. He completed neoadjuvant chemoradiation
therapy and now presents for definitive surgery with a minimally
invasive esophagectomy with gastric pull-up in cooperation with
Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] of Thoracic Surgery.
Past Medical History:
PMH: Esophageal cancer, poorly differentiated adenocarcinoma,
EUS showing T3 lesion, s/p neoadjuvant chemoradiotherapy,
Hypertension, Hyperlipidemia, Rheumatoid arthritis, Hemorrhoids,
GERD
PSH: hemorrhoidectomy, laparoscopic cholecystectomy,
rhinoplasty, and tooth extraction
Social History:
He lives in [**Location (un) **] and worked as a property manager but was
just laid off. He has a significant other - [**Name (NI) 16883**] - who has
been helping to take care of him. He was formerly a heavy
drinker, however, cut back in the last 10 years or so,
now drinks two to three drinks a night, although less recently.
He smoked three packs a day for 30 years but quit 35 years ago.
No illicits.
Family History:
Family History:
- Mother: uterine cancer in her 70s
- Father: CAD, colon cancer in his 50s
- Brother with multiple dystrophy
- Brother: prostate cancer.
Physical Exam:
At surgical consultation:
On physical examination, he is a well-developed gentleman. Head,
eyes, ears, nose, and throat are normal. He has dentures. The
neck is supple, without mass, nodes, or thyromegaly. Chest is
clear to percussion and auscultation. Heart sounds are regular
without murmurs or gallops. The abdomen is soft without
tenderness, mass, or organomegaly. There are well-healed
laparoscopic scars. Extremities are without cyanosis, clubbing,
or edema. He is neurologically intact.
Pertinent Results:
PET Scan [**2112-11-7**]: 1. Marked FDG-avidity at the gastroesophageal
junction, compatible with known carcinoma. 2. No metastatic
disease identified.
Barium esophagogram [**2113-3-6**]: 1. No leak at the site of
anastomosis.
2. Pneumoperitoneum, which is expected post-surgically,
unchanged from [**2113-3-5**].
Brief Hospital Course:
Mr. [**Known lastname 25006**] [**Last Name (Titles) 1834**] minimally invasive esophagectomy with
gastric pull-up on [**2113-2-28**] and was admitted to the General
Surgery service. Immediately after the surgery, he was taken,
after being extubated, to the Surgical ICU for close monitoring.
Overall, he had a smooth hospital course and was discharged home
on Post-op day 9 in stable condition. His post-operative course
is summarized below by system.
Neuro: While NPO, the patient received IV narcotics with good
effect. This was transitioned to liquid oxycodone and liquid
acetaminophen after he began taken POs and he was discharged
with pain well controlled on oral medications. He has baseline
anxiety which was treated while in house with benzodiazapines
with satisfactory effect.
CV/Fluids/Electrolytes: The patient received adequate fluids
postop and was bolused as needed to maintain SBP. Pressors were
avoided in order to protect the anastamosis. The patient
responded well to these interventions and there were no major
issues during his stay. He received metoprolol IV while NPO and
had some ectopy thought to be related to low Mg, which was
repleted. He was put back on his home dose of atenolol after he
was able to tolerate them enterally. His EKG did not show any
concerning changes.
Pulm: The chest tubes were kept until after the patient had his
barium swallow on POD 6 and it was read as negative. The chest
tubes as well as the neck JP were removed on POD 7. Of note, he
had been complaining of severe back pain thought to be related
to irritation from the chest tubes. EKGs were performed to
assure us that it was not cardiac in origin. This pain
completely resolved with removal of the tubes.
GI/Nutrition: The patient had had previous placement of a Jtube
and had been receiving tube feeds at home. On POD 2, these tube
feeds were restarted through the Jtube for nutritional support.
On POD6, the NGT was removed after a negative barium swallow and
he was started on a clear liquid diet. On POD7, he was advanced
to a soft solid diet, on which he was discharged.
GU: After the patient became ambulatory and was thought able to
handle urinating on his own, the foley catheter was removed and
he was able to void without issue.
ID: The patient received routine antibiotic prophylaxis in the
perioperative period. These were appropriately discontinued
postop.
Heme: The patient had baseline anemia prior to the operation,
requiring transfusions in the months prior to the operation.
Postop, the patient did well, but was noted to have a low
hematocrit. In order to protect the anastamosis, he was
transfused three units packed red blood cells to maintain a
hematocrit of 30. After the initial postop period, he required
no further transfusions.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
2. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
Disp:*600 mL* Refills:*2*
3. Oxycodone 5 mg/5 mL Solution Sig: [**4-10**] mL PO Q3H (every 3
hours) as needed for pain.
Disp:*300 mL* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain .
Disp:*50 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*50 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Peptamen 1.5 Liquid Sig: Seventy Five (75) cc PO qhour:
Please run 75 cc/hr cycled over 12 hours at night.
Disp:*120 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
esophageal cancer s/p esophagectomy with gastric pull-up
Atrial ectopy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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 [**4-10**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**3-27**] at 3:45 in his
office.
Call Dr.[**Name (NI) 1482**] office at ([**Telephone/Fax (1) 1483**] for any problems
before then.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD Phone:[**0-0-**]
Date/Time:[**2113-4-13**] 2:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2113-4-13**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15105**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2113-4-13**] 2:30
Your port was deaccessed and heparin locked today ([**2113-3-9**]).
Please remember to get your port flushed and heparin locked per
nursing protocol every month.
ICD9 Codes: 5859, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4516
} | Medical Text: Admission Date: [**2183-1-1**] Discharge Date: [**2183-1-3**]
Date of Birth: [**2136-4-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 46M who presents with a 1 week h/o worsening
abdominal pain. The patient states that this pain is
intermittent, primarily epigastric, sharp, with radiation to the
RUQ/LUQ. He states that this pain has been getting gradually
worse over the past week. He endorses early satiety and
inability
to move bowels. He initially believed that he was just
constipated. Today, he reports his pain to be increasingly
worse.
He reports nausea with emesis x1 that was just regurgitated
food.
He now presents for further care.
Past Medical History:
gout, GERD
Social History:
Patient reports drinking [**11-23**] pint to 1 pint of Schnops per
day, he denies tobacco/illicit drug abuse
Family History:
Non-contributory
Physical Exam:
On presentation
VS: 98.7 136 154/102 22 98%RA
General: awake and alert
CV: tachycardic
Lungs: CTA bilaterally
Abdomen: soft, non-distended, hypoactive BS, no
rebound-guarding
Ext: warm, no edema
Pertinent Results:
[**2183-1-1**] 06:51PM LACTATE-1.0
[**2183-1-1**] 06:45PM GLUCOSE-117* UREA N-8 CREAT-0.9 SODIUM-141
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16
[**2183-1-1**] 06:45PM estGFR-Using this
[**2183-1-1**] 06:45PM ALT(SGPT)-23 AST(SGOT)-28 ALK PHOS-90 TOT
BILI-1.1
[**2183-1-1**] 06:45PM LIPASE-2198*
[**2183-1-1**] 06:45PM WBC-12.6* RBC-4.42* HGB-14.4 HCT-43.4 MCV-98
MCH-32.6* MCHC-33.2 RDW-14.0
[**2183-1-1**] 06:45PM NEUTS-85.9* LYMPHS-8.5* MONOS-5.1 EOS-0.1
BASOS-0.3
[**2183-1-1**] 06:45PM NEUTS-85.9* LYMPHS-8.5* MONOS-5.1 EOS-0.1
BASOS-0.3
[**2183-1-1**] 06:45PM PLT COUNT-323
[**2183-1-1**] 06:45PM PT-12.3 PTT-21.2* INR(PT)-1.0
Brief Hospital Course:
46 y/o M presented with first episode of alcohol induced
pancreatitis of one weeks duration. Admitted to the SICU [**2183-1-1**]
with sinus tachycardia to 130's, normotensive with good urine
output. On [**2183-1-2**] patient appeared comfortable, with good UOP
and tachy to 130[**Hospital **] transferred to floor. On floor patient was
noted to be anxious with sinus tachy to 130's but normotensive
with good UOP throughout. Patient's tachycardia increased to
140-150, EKG obtained by HO demonstrated sinus tachy without any
new EKG changes. HR peaked at 169 at approx 9:30, Patient seen
by HO and noted to be anxious but without chest pain, shortness
of breath, nausea or any focal neurological deficits. 5mg IV
Lopressor Q4H started at approx 10:00pm. At 11:45 patient found
unresponsive by [**Name6 (MD) **] and RN. Code blue called immediately and ACLS
instituted. Patient found to be in PEA arrest. Two rounds of
atropine, epi + vasopressin given. Patient was intubated and
briefly regained a thready pulse before reverting back to PEA.
After three rounds of meds/chest compressions patient regained
weak pulsed and was quickly transferred to SICU. Soon after
arrival patient reverted to PEA and ACLS was again reinstituted
at 00:30. Epi x 4, atropine x 4, bicarb x 4 + IVF. 00:57 pulse
regained with spurts of respiratory motion, (HR: 139 BP: 91/63).
CXR obtain with ETT in good position, no overt ARDS, no
pneumothorax or hemothorax. Crystalloids and pressors increased.
Attending made aware. 1:03 Patient reverted to PEA, chest
compressions resumed. Pulse not regained despite 6 rounds of
meds in SICU. Time of death 1:13. Attending notified. Spouse
notified. ME declined exam. Permission for autopsy obtained.
Medications on Admission:
allopurinol, protonix
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Acute pancreatitis
Secondary: Cardiopulmonary arrest
Discharge Condition:
Expired
ICD9 Codes: 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4517
} | Medical Text: Admission Date: [**2158-3-1**] Discharge Date: [**2158-3-7**]
Date of Birth: [**2082-10-9**] Sex: M
Service: C-MED
CHIEF COMPLAINT: Left elbow pain.
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
a long history of coronary artery disease (status post
coronary artery bypass graft in [**2138**], multiple
catheterizations and interventions), hypertension,
hyperlipidemia, past tobacco history, family history of
coronary artery disease, who reports a long history of angina
manifested as left elbow pain. However, prior to this week,
angina occurred twice a week on average with episodes lasting
only a few minutes reaching about [**2-11**] in intensity. Then,
two days prior to this admission the patient began noticing
increasing elbow pain that waxed and waned over the next few
days but never completely subsided. The pain was limited to
the left elbow, reached as high as [**4-13**] to [**5-14**], and was not
accompanied by shortness of breath, chest pain, palpitations,
nausea, vomiting or diaphoresis. He took sublingual
nitroglycerin without relief, only later realizing that his
nitroglycerin had long ago expired. When pain persisted, he
presented to the doctor today and was subsequently referred
to the emergency department.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post 4-vessel coronary
artery bypass graft in [**2148**] (saphenous vein graft to D1, left
anterior descending artery, first obtuse marginal, posterior
descending artery); status post percutaneous transluminal
coronary angioplasty in [**2152-4-3**] after an acute myocardial
infarction with stenting of the saphenous vein graft to the
first obtuse marginal (95% occlusion); [**2152-11-3**]
catheterization with 40% lesion in the saphenous vein graft
to the right coronary artery and a 90% lesion in the
saphenous vein graft to first obtuse marginal which was
stented times two; [**2154-11-4**] catheterization and
percutaneous transluminal coronary angioplasty with stenting
of saphenous vein graft to right coronary artery; [**2155-11-4**] catheterization with percutaneous transluminal coronary
angioplasty and stenting of the left circumflex.
2. Hypertension.
3. Hyperlipidemia.
4. Abdominal aortic aneurysm (4 cm in diameter; has been
stable; followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]).
5. Prostate cancer.
6. Renal cell carcinoma, status post nephrectomy in [**2156-2-2**]
7. Chronic renal insufficiency.
8. Colitis.
9. Degenerative joint disease, especially of the right hip
and lower spine.
10. Bilateral inguinal hernia repair.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Isordil 20 mg p.o. t.i.d.
3. Norvasc 10 mg p.o. q.d.
4. Lopressor 100 mg p.o. b.i.d.
5. Accupril 40 mg p.o. q.d.
6. Cardura 4 mg p.o. b.i.d.
7. Lipitor 40 mg p.o. q.d.
8. Sublingual nitroglycerin 0.3 mg p.r.n.
SOCIAL HISTORY: The patient is married and lives with his
son. The patient has lived in a nursing home since [**2156-11-3**]. He worked in a furniture warehouse. He denies
alcohol use. He does have greater than a 90-pack-year
smoking history, but he quit in [**2138**].
FAMILY HISTORY: His sister died of heart disease at age 65.
Father died of heart disease at age 78. Family history also
positive for diabetes.
PHYSICAL EXAMINATION: Heart rate 92, blood pressure 136/80,
97% oxygen saturation nasal cannula. In general, the patient
was pleasant, comfortable, in no apparent distress. HEENT
revealed arcus senilis bilaterally anicteric. Pupils were
equal, round and reactive to light. Extraocular movements
were intact. Moist mucous membranes. No oral lesions. Neck
was supple. No lymphadenopathy. No bruits. No jugular
venous distention. Lungs were clear to auscultation
bilaterally. Heart had a regular rate and rhythm, normal S1
and S2. No murmurs, rubs or gallops. Abdomen had positive
bowel sounds, soft, obese, nontender. Extremities with 1+
bilateral lower extremity pretibial edema, 2+ posterior
tibialis pulses bilaterally, 1+ dorsalis pedis pulses
bilaterally, 2+ femoral pulses bilaterally. No bruits.
Rectal was OB negative per emergency department.
LABORATORY: CBC with a white blood cell count of 6,
hematocrit 40.2, platelets 190. Chem-7 revealed sodium
of 140, potassium 4.8, chloride 105, bicarbonate 23, BUN 27,
creatinine 1.7, glucose 95. Coagulations revealed an
INR of 1, PTT 26.1. Creatine kinase 125, MB 10, MB index 8,
troponin 2.5. Peak creatine kinase 209. Peak MB 26 with an
MB index of 12. Troponin I of 12.4.
Electrocardiogram revealed normal sinus rhythm at 92 beats
per minute, right bundle-branch block, borderline
first-degree AV block, axis 93 degrees, 1-mm ST elevations in
V4 through V6 (new compared with electrocardiogram from
[**2156-6-24**]).
[**2158-3-2**], catheterization revealed a right-dominant
system and 3-vessel disease. Left main was normal. Left
anterior descending artery totally occluded proximally.
Right coronary artery totally occluded proximally. Left
circumflex proximal 60% stenosis. Regarding the patient's
grafts: Saphenous vein graft to left anterior descending
artery with no stenosis, saphenous vein graft to posterior
descending artery with 90% proximal, 50% in-stent stenosis,
saphenous vein graft to left circumflex was patent with
native obtuse marginal with 80% lesion.
Ventriculography revealed an ejection fraction of 52%.
The patient underwent successful percutaneous transluminal
coronary angioplasty of saphenous vein graft to posterior
descending artery with direct stenting of the proximal
lesion. In addition, percutaneous transluminal coronary
angioplasty was done on the in-stent restenosis of the
saphenous vein graft to posterior descending artery with less
than 20% residual stenosis and TIMI-III flow.
Chest x-ray showed no evidence of cardiopulmonary process.
[**3-3**] ultrasound on right groin revealed a 2-cm to 2.5-cm
round pseudoaneurysm at the common femoral artery. A repeat
ultrasound on [**2158-3-6**], with Duplex color Doppler
revealed no evidence of pseudoaneurysm, hematoma, or AV
fistula.
Echocardiogram revealed left atrial moderate dilatation,
interatrial septum (consistent with right atrial pressure),
mild left ventricular hypertrophy, ejection fraction of
question 35%, hypokinetic anterolateral wall and akinetic
inferoposterior wall with mild 1 to 2+ mitral regurgitation.
HOSPITAL COURSE: This is a 75-year-old male with a history
of hypertension, hyperlipidemia, coronary artery disease,
status post coronary artery bypass graft and multiple
interventions, and smoking who presented with five hours of
resting angina partially relieved by nitroglycerin.
Electrocardiogram with ST elevations in V4 through V6 and
enzymes that ruled in for an acute myocardial infarction.
The patient was admitted to Eleven Riseman and started on IV
nitroglycerin, continued on beta blocker, heparin, and
aspirin. He was placed on Integrilin and taken to cardiac
catheterization on [**3-2**].
Catheterization revealed 3-vessel disease with totally
occluded right coronary artery and left anterior descending
artery, 90% proximal stenosis and 50% in-stent stenosis of
the saphenous vein graft to posterior descending artery
graft, native obtuse marginal 80% lesion, 60% proximal left
circumflex lesion. His saphenous vein graft to left anterior
descending artery graft revealed no stenosis, and the
saphenous vein graft to left circumflex graft was patent.
The patient had percutaneous transluminal coronary
angioplasty and stents placed to his 90% proximal saphenous
vein graft to posterior descending artery graft leading to 0%
residual stenosis. The patient also had percutaneous
transluminal coronary angioplasty to dilate the in-stent
stenosis of the saphenous vein graft to posterior descending
artery which lead to less than 20% residual stenosis and
TIMI-III flow. Catheterization also revealed mild
ventricular systolic and diastolic dysfunction.
The patient's post catheterization course was complicated by
a right femoral pseudoaneurysm measuring 2 cm to 2.5 cm.
This occurred over the weekend, and the patient was scheduled
to have thrombin injection on Monday; however, a repeat
ultrasound on Monday (two days after appearance of the bruit)
revealed no evidence of pseudoaneurysm. On the following day
the patient saw physical therapy and was discharged home.
Of note, the patient's cardiac medications were maximized
during his hospitalization. His Lopressor originally 50 mg
b.i.d. was increased to as much as 100 mg and then gradually
decreased back down to 50 mg because of bradycardia to the
40s with sinus pauses of 2 seconds. Because the patient was
still hypertensive with mild ventricular systolic
dysfunction, captopril was started and increased to 75 mg
p.o. t.i.d. Further adjustments should be made as an
outpatient.
On the day of discharge, the patient complained of greenish
left eye discharge with crusting. Eye was mildly injected.
He will be sent home with antibiotic drops to treat
conjunctivitis.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction.
2. 3-vessel coronary artery disease.
3. Successful percutaneous transluminal coronary angioplasty
and stent of proximal saphenous vein graft to posterior
descending artery lesion. In addition, successful
percutaneous transluminal coronary angioplasty of in-stent
stenosis within the saphenous vein graft to posterior
descending artery.
4. Right groin pseudoaneurysm, self resolved.
5. Left eye conjunctivitis.
6. Hypertension.
Rest of diagnoses as per past medical history.
MEDICATIONS ON DISCHARGE:
1. Polytrim 1 drop three times a day times seven days to
left eye.
2. Plavix 75 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 40 mg p.o. q.d.
5. Captopril 75 mg p.o. t.i.d.
6. Lopressor 50 mg p.o. b.i.d.
7. Cardura 4 mg p.o. q.d.
8. Sublingual nitroglycerin 0.3 mg p.r.n.
FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 105949**] (Cardiology) in two to four weeks.
2. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **](Vascular
Surgery); the patient was to call for followup.
3. Follow up with Dr. [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) 2450**]; the patient was to call
for followup.
CONDITION AT DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 13956**]
MEDQUIST36
D: [**2158-3-7**] 13:14
T: [**2158-3-7**] 13:53
JOB#: [**Job Number 48573**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4518
} | Medical Text: Admission Date: [**2107-1-1**] Discharge Date: [**2107-1-2**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This 82-year-old white male with
a history of CVAs and severe rheumatoid arthritis who
presented to the [**Hospital6 256**] as a
transfer from an outside hospital with rapid atrial
fibrillation and chest pain. The patient initially presented
to his urologist's office the morning of the 29th complaining
of right-sided chest pain and flank pain, which had been
present for one month, but was worse on the day of admission.
The patient pain presented as sharp, nonexertional, mildly
pleuritic, not associated with shortness of breath, nausea,
vomiting or diaphoresis. The patient was sent home from the
doctor's office after being told he was fine but called his
doctor when he found himself unable to rise from a chair at
home. The patient was found by EMS to be tachypneic with
heart rates in the 220s, irregular, with stable blood
pressure. He was given adenosine up to 12 mg with no effect.
He then received 20 mg intravenous diltiazem with heart rate
in the 150s.
The patient arrived at [**Hospital3 **] in the Emergency Room
with a heart rate of 136. Systolic blood pressure of 92. He
was given diltiazem .25 mg intravenous times one and then a
drip was started at 15 mg per hour. On interview, patient
gave clear history of sudden onset of chest pressure at 2
p.m., mildly pleuritic with diaphoresis, mild shortness of
breath, no electrocardiogram changes. The first enzymes were
negative. Blood pressure support was attempted with two
liters normal saline. The 02 saturations decreased. Patient
was given esmolol drip, GTT, and then his heart rate down to
the 90s but systolic blood pressure continued to be in the
90s. Dopamine drip was then added when the systolic blood
pressure went down to the 60s. Chest x-ray was consistent
with congestive heart failure and D dimer returned positive
so heparin was started. The decision was made to transfer
the patient to the [**Hospital6 256**] at
that point. They added Levophed to increase the blood
pressure and Ceftriaxone was given empirically without blood
cultures being drawn. The patient was transferred to [**Hospital6 1760**] with stable blood pressure on
Levophed, dopamine, diltiazem drip and esmolol drip. The
Esmolol drip and the diltiazem drip were discontinued on
arrival at [**Hospital6 256**]. Also
discontinued secondary to his low blood pressure. Vancomycin
and Flagyl were given for presumptive sepsis.
[**Hospital **] MEDICAL HISTORY: Significant for rheumatoid
arthritis, CVA in [**2100**] with no deficiencies and a
questionable possibility of having a transurethral resection
of prostate back in [**2097**].
ALLERGIES: He had no known drug allergies.
MEDICATIONS ON ADMISSION: Codeine, Celebrex, prednisone 5 mg
po q.d., Prilosec, Methotrexate, aspirin, folate, Axid and
Xanax.
SOCIAL HISTORY: Patient quit cigarettes when he was in his
60s. He does not drink alcohol. Lives in [**Location (un) 5503**],
[**State 350**] with his wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 99.1. Heart rate of
121-126. Heart rate 16-20. Blood pressure 112/72. 02
saturation 96% on 100% nonrebreather. Patient was alert and
responsive. Pupils equal, round and reactive. Extraocular
motions intact and full. Oropharynx was unremarkable. Neck
was in a tag collar, no lymphadenopathy, no jugular venous
distention noticed. Heart was irregularly irregular with no
murmurs, rubs or gallops. Lungs showed diffuse loud crackles
bilaterally. Abdomen was soft, nondistended, nontender with
positive bowel sounds. Extremities showed trace pedal edema,
1+ pedal pulses bilaterally, the right groin femoral line was
in place and was a triple lumen catheter.
HOSPITAL COURSE: On admission to the Medical Intensive Care
Unit, the patient began to decompensate both from a blood
pressure and a respiratory prospective. He was ultimately
intubated around 3 p.m. and his blood pressure was maintained
with four different pressor agents including vasopressin,
dopamine, phenylephrine and Levophed. He was also given
antibiotics including ceftazidime, vancomycin and Flagyl
overall for presumed sepsis. The patient's blood pressure
did not increase and in conversation with the family, the
patient was made "Do Not Resuscitate." His blood pressure
and heart rate continued to decline. He was unable to be
maintained and his heart eventually stopping and the
ventilator was then discontinued. He was pronounced dead at
12:55 a.m. on the [**1-2**] for presumed sepsis leading to
cardiovascular collapse, respiratory failure, respiratory
arrest and cardiac arrest. The family agreed to having an
autopsy performed.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2107-1-7**] 13:54
T: [**2107-1-7**] 13:54
JOB#: [**Job Number 37581**]
ICD9 Codes: 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4519
} | Medical Text: Admission Date: [**2167-1-20**] Discharge Date: [**2167-1-22**]
Date of Birth: [**2097-4-29**] Sex: M
Service: MEDICINE
Allergies:
Ranitidine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain/shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization [**2167-1-20**]
History of Present Illness:
69M CAD s/p CABG in [**2152**], DM2, CKD on HD, radiation cystitis
complicated by enterococcal UTI ([**1-21**]) and history of
enterococcal endocarditis presenting with chest pain and dyspnea
on exertion for several weeks responsive to nitroglycerin. He
noticed that pain occasionally radiated to bilateral arms. He
denies fevers, chills, nausea/vomiting. He also denies PND or
orthopnea.
Patient was due for outpatient c. cath on Thursday with his
cardiologist Dr. [**Last Name (STitle) **]. He was advised to present to the ED
given increased frequency and intensity of chest discomfort. He
initially presented to OSH and was transferred here due to
cardiology care here. He states that the reason why he came
today was that he usually uses oxygen at HD sessions, but his
doctor told him that he can't do that on a regular basis. It was
also ascertained that for the past 3 weeks that he was using
[**8-21**] SLNTGs a day for chest discomfort occuring both at rest and
with exertion. This represents increased frequency of his
symptoms - intensity has been the same.
Of note, he also was complained about needing oxygen and
subsequently is doing well on 3 L NC. He does endorse some chest
congestion now.
.
In the ED, initial VS: 22:34 0 98.1 91 101/51 18 100% 3L.
ECG showed SR at 95 bpm with lateral ST depression and no STEMI.
There were some dynamic depressions in V4-V5 while patient was
chest pain free on arrival here.
OSH labs at 8 PM showing WBC 6.3, Hgb 12.4, Plt 156. Chemistry
panel was Na 134, K 3.7, Cl 90, HCO3 30, BUN 35, Cr 2.8 and
Glucose 132. Troponin I was 0.03.
A bedside ECHO in the ER showed no effusion with an EF of about
40 % with poor lateral squeeze. CXR showed mild volume overload
and airspace pulmonary edema. He was guiaic negative on exam.
He also did have active chest pain at 11:15 PM relieved by
sublingal nitroglycerin. A repeat ECG did showed worsening
depression in V3 and improved in V5. The attending cardiologist
assessed him in the ER, recommended heparin infusion and
nitroglycerin infusion given frequent chest discomfort.
Initial labs showed Cr 3.4 (HD patient), anion gap 22, TropnT
0.04. Hgb was 12.3 near baseline.
VS on transfer were: 105/49, 88, 18, 100% 3L nc
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG x 4 '[**52**] (LIMA-LAD, SVG-OM, SVG-D1, SVG-PDA)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2160**]: Two 2.5 Cypher
stents and a 3.0 Cypher stent were placed in the LM and RI.
in [**2161**]: drug-eluting stent placed in the ramus intermedius.
- History of enterococcal endocarditis
.
3. OTHER PAST MEDICAL HISTORY:
Prostate Cancer s/p Radical prostatectomy and XRT in [**2162**]
Radiation cystitis s/p 60 hyperbaric oxygen treatments in [**2164**],
Clot irrigation [**10-21**], transfusions, silver nitrate irrigation,
Colon cancer stage III s/p colectomy/postop FOLFOX
GERD
Sigmoid colectomy, [**2162**]
Cystoscopy, clot evacuation, [**10/2165**]
Cystoscopy, formulin instillation [**2165-12-28**]
Hypertension
Diabetes Mellitus Type 2
.
PSH:
s/p CABG x4 [**2152**]
s/p prostatectomy
s/p appendectomy in [**2160**]
s/p cholecystectomy [**2159**]
s/p ear, tonsil and adenoid surgery
s/p femoral rodding
s/p back surgery
Social History:
Retired estimator for an environmental company. Lives with wife.
Quit smoking in [**2165-12-11**], but previously smoked [**1-12**] ppd (~120
pack years). Previously drank ~ [**1-12**] case of beer daily, now
sober for many years. Denies illicit drug use.
Family History:
Unknown, as the patient does not know his biological parents.
Physical Exam:
ADMISSION EXAM
VS T 97.9 BP 110/62 HR 98 RR 20 pOx 95 on 2L Weight: 59.6 kg
GENERAL - well-appearing in NAD, comfortable, appropriate
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 - PMI non-displaced, RRR, + SEM, 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)
+ bruit in LUE dialysis fistula
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout,
DTRs 2+, gait deferred.
DISCHARGE EXAM
pt pulseless, without corneal reflex, without heart sounds.
Pertinent Results:
# LABORATORY DATA
.
ADMISSION LABS
[**2167-1-19**] 11:30PM BLOOD WBC-5.9 RBC-3.64* Hgb-12.3* Hct-36.2*
MCV-99* MCH-33.9* MCHC-34.1 RDW-14.2 Plt Ct-165
[**2167-1-19**] 11:30PM BLOOD Neuts-77.9* Lymphs-14.5* Monos-5.5
Eos-1.8 Baso-0.4
[**2167-1-19**] 11:30PM BLOOD PT-12.7* PTT-29.0 INR(PT)-1.2*
[**2167-1-19**] 11:30PM BLOOD Glucose-142* UreaN-42* Creat-3.4* Na-137
K-4.2 Cl-97 HCO3-22 AnGap-22*
[**2167-1-22**] creatinine up to 3.5
CARDIAC BIOMARKERS
[**2167-1-19**] 11:30PM BLOOD cTropnT-0.04*
[**2167-1-20**] 07:40AM BLOOD CK-MB-1 cTropnT-0.04*
[**2167-1-20**] 07:40AM BLOOD CK(CPK)-8*, CKMB 1
# IMAGING
CXR (Portable) [**2167-1-19**]
CHEST, AP: Right dialysis catheter again terminates in the mid
right atrium. Lungs are overinflated, with biapical
hyperlucency. There is new right lower lobe opacity with
obscuration of the hemidiaphragm. Increasing volume overload
with mild cardiomegaly, central venous congestion, and
interstitial/early airspace pulmonary edema. Probable small left
effusion. CABG changes are noted, with median sternotomy wires
and mediastinal clips.
IMPRESSION:
1. Possible right lower lobe pneumonia.
2. Increasing volume overload.
.
cardiac cath
# CARDIAC CATHETERIZATION [**2167-1-20**]
(Prelim report was up)
COMMENTS:
1. Selective native coronary angiography of this right dominant
system
demonstrated severe 2 vessel coronary artery disease. The RCA
was not
engaged due to it having a known total occlusion. The LMCA had
minimal
non-angiographically significant coronary artery disease with a
patent
stent. The LAD had a proximal total occlusion. The LCX had a
proximal
total occlusion. The ramus had a patent stent with minimal
non-angiographically significant coronary artery disease.
2. Selective venous conduit angiography demonstrated widely
patent SVG
to PDA, and SVG to Diagnoal grafts. The SVG to OM graft was
patent,
with a 60% stenosis at the ostium of the bypassed OM at its
point of
attachment to the LCX.
3. Selective arterial conduit angiography demonstrated a widely
patent LIMA to LAD graft. The distal native LAD had a 80%
lesion.
4. Successful balloon angioplasty of the LAD with a 2.0 x 8 mm
balloon
(see PTCA comments).
FINAL DIAGNOSIS:
1. Severe two vessel native coronary artery disease (RCA not
evaluated
due to a known total occlusion)
2. Patent LIMA to LAD graft with an 80% stenosis in the distal
native
LAD.
3. Patent SVG to Diagonal, SVG to PDA, and SVG to OM grafts.
4. Mild asymptomatic systemic arterial hypotension.
5. Successful POBA of the LAD with a 2.0 x 8 mm balloon.
.
TTE [**2167-1-20**]
Moderately dilated left ventricle. Regional left ventricular
systolic dysfunction c/w CAD. Probable small vegetation on
aortic valve, right coronary cusp. Moderate aortic
regurgitation. Moderate mitral regurgitation. At least moderate
pulmonary hypertension. Mild right ventricular global
hypokinesis. Compared with the prior study (images reviewed) of
[**2166-9-12**], regional left ventricular systolic dysfunction is more
extensive (distal LAD territory). The severity of pulmonary
hypertension has increased. There is right ventricular
dysfunction. The aortic valve vegetation appears similar in
size.
Brief Hospital Course:
69 yo M with CAD s/p CABG ([**2152**]), DMII, and ESRD presenting with
worsening chest pains and DOE. He had been taking multiple
nitroglycerin tabs daily ([**8-21**]) in addition to his long acting
nitrates. He was scheduled for outpatient cath 2 days from
admission, however presented to the ED with worsening frequency
and severity of his chest pains. He was started on heparin and
nitro drips and admitted to the cardiology floor. He continued
to have chest pains overnight and was was taken to the cath lab
on the morning of [**1-20**]. Received 600mg plavix, bivalirudin, no
stents placed. balloon angioplasty to LAD. During the cath, he
continued to have chest pains. He contined to have lateral ST
depressions on his EKG after the procedure. He was initially
chest pain free after the procedure, however his chest pains
have returned and he was to be transferred to the CCU for
further management.
.
# Acute coronary syndrome - presented with increased freq of CP
including at rest with troponins slightly elevated. Pt to cath
lab [**2167-1-20**], with severe 2 vessel native disease RCA with total
occlusion, patent grafts, balloon angioplasty to LAD, unable to
access circ lesion. Cath also showed patent LIMA to LAD graft
and patent SVG to OM, SVG to Diagonal, and SVG to PDA grafts. Pt
to CCU for monitoring. He was given 25mg metoprolol after cath.
On transfer to the CCU (after several hours chest pain free) pt
developed [**6-21**] chest pressure. Nitro drip was increased to 1.2
with good resolution of pain. ECG with 1mm elevations in V1, V2
with 1mm depressions V3-V5. Pt was sleeping calmly following
this episode. That afternoon pt with acute episode of
diaphoresis, chest pain, and dyspnea. O2 sats 95 on 3L nc, BP
80s/40s so limited in ability to uptitrate nitro drip which was
at 1.2. ECG showed depressions in antero-lateral leads unchanged
from ECGs from prior. got ipratropium nebs (HR was high 90s) and
klonipin. within 10-20 minutes pt was without dyspnea/CP, stated
that he had a lot of anxiety about the procedure not able to
open up the circ lesion.
Nitro gtt was continued, eventually weaned and pt put on home
dose imdur. Pt continued to have episodes of [**6-21**] chest pain but
ECGs were all with stable anterolateral depressions. Even when
CP resolved ECGs with those findings. Pt was continued on
atorvastatin, aspirin, plavix, and metoprolol. His blood
pressures remained in the 80s/40s, appears his b/l roughly
around this range, but this limited our ability to increase
nitro. Imdur was held.
.
#PEA ARREST - on the day of arrest [**2167-1-22**] pt had been asx with
hypotension 70s-80s during the morning via NIBP. Pt continuing
to c/o of recurring dull aching chest pain which was pleuritic
and reproducible with palpation. Pt very anxious when staff not
in room with him. Pt given ativan 0.5mg po x 1 at 0730hrs and
tylenol with slight decrease in anxiety and pain. No further c/o
of chest pain since 1100hrs. Rt radial Aline placed by team
with ABP initially 90s decreasing to 70-80s. Obtained double
lumen PICC line Right brachial. Started po midodrine for low BP.
Started Neo with little effect on SBP SBP 78 on 3mcg/kg/min.
Initally attempting to start CRRT at 1330hrs with slight
decrease in SBP but filter malfunctioned and blood returned and
new filter set up re-set up. CRRT re-started with no fluid
removal at 1500hrs ?????? titrated up Neo to 5mcg/kg/min when sBP
started to decreased to low 70s ?????? for ~2min had increased fluid
removal rate to remove only IVF that were being given to patient
for CRRT but turned it back down to zero for no fluid removal
when SBP decreasing to low 70s then turned off CRRT when BP
dropped to 60s ?????? pt became unresponsive and CODE called. Pt was
in PEA, then junctional, back to PEA then vfib ?????? shocked 6
times, CPR throughout code situation, multiple code meds given
including epi, amio, lido. return of blood pressure and pulse
after initiation of 5 pressors. Family was in contact with CCU
team ?????? code called at 1555hrs after 45 minutes of coding. Family
stated not to escalate care. Approximately 2L IVF given during
code. ABP 70s with a bradycardic rhythm with weak pulse until pt
became hypotensive and asystolic, time of death 1631hrs. Family
+ HCP [**Name (NI) 18659**] notified and one Son [**Name (NI) 12239**] and Grandson came in to
visit, rest of family staying home, belongings given to family.
.
#CAD: Pt with ACS, cath showed 2 vessel disease see ACS above.
Echo showed compared with the prior study of [**2166-9-12**], regional
left ventricular systolic dysfunction is more extensive (distal
LAD territory). The severity of pulmonary hypertension has
increased. There is right ventricular dysfunction. The aortic
valve vegetation appears similar in size. Started pt on beta
blocker (not part of home regimen).
.
#hypotension - pt with blood pressure in 80s/40s which appears
to be around his baseline. He receives midodrine at dialysis as
he has a history of hypotension with dialysis. Was placed on
nitro gtt for continued chest pain but eventually weaned and
placed back on home imdur. Hypotension was felt most likely [**2-12**]
underlying cardiac dysfunction exacerbated by nitro drip,
although hypotension persisted. Pt was monitored on telemetry.
.
#dyspnea - pt with new O2 requirement of 2-3L nasal cannula but
satting high 90s-100 on this regimen. Satting well. Seems that
he probably needed to be on O2 at home as he c/o significant
dyspnea prior to admission. H/o 50 years of smoking, likely pt
with component of COPD - on advair at home which was continued.
Pt also given nebulizer treatments with good effect. O2 sats
consistently monitored and remained in the mid-high 90s.
.
# Chronic systolic heart failure
Patient last had dialysis on Monday with CXR suggesting mild
volume overload, now also requiring oxygen. Uncertain if pt
presented with true heart failure exacerbation from increased
demand ischemia vs. insufficient HD. Echo in [**2166-9-11**] showed
LVEF of 50-55%. Volume status closely monitored. Pt was putting
out minimal urine and lasix bolus and drip were attempted
without good effect. See ESRD below.
.
# ESRD - pt receiving HD twice weekly. Pt gets midodrine prior
to HD to maintain BPs. Medications were renally dosed.
Renal/dialysis was following the patient. CRRT was initiated on
[**2167-1-22**] around 2pm for worsening renal function as seen via
creatinine and potassium elevations. It was also felt that
significant fluid overload could be contributing to pulmonary
edema which would explain his dyspnea.
.
Pt was maintained as full code throughout the course of this
hospitalization.
.
contact: son [**Name (NI) 18659**] cell [**Telephone/Fax (1) 18660**]
Medications on Admission:
1. Mucinex 600 mg PO BID
2. ASA 81 mg PO qAM
3. Renal Caps PO qAM
4. Trazodone 50 mg PO qHS
5. Clonazepam 0.5 mg PO before dialysis and qHS
6. Midodrine 5 mg PO before dialysis
7. Albuterol 2.5 mg ? INH 2x/day
8. Align PO qD
9. Levemir insulin
10. Clobetasol propionate ointment
11. Pravastatin 40 mg PO qHS
12. Isosorbide 60 mg PO BID
13. Ranexa 1000 mg PO qAM
14. Nitrostat prn chest pain
15. Symbicort 4.5 mg
16. Diphen/atropine 2-3x/day (per patient)
Discharge Medications:
n/a pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
ICD9 Codes: 5856, 4168, 4280, 496, 4111, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4520
} | Medical Text: Admission Date: [**2166-8-12**] Discharge Date: [**2166-9-12**]
Date of Birth: [**2090-9-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
gentleman presenting to [**Hospital1 69**]
emergency department on [**2166-8-12**] complaining of 24 hours of
dizziness, shortness of breath, cough, fever and respiratory
distress. Patient was noted to have a significant past
medical history of upper GI bleed and was status post one
episode of coffee ground emesis the night prior to admission.
Patient was found to be in mild respiratory distress with
bilateral rhonchi, hypoxia and hypercapnia. Patient became
significantly more hypoxic and hypercapnic and anesthesia was
called for potential difficult airway and patient was
successfully intubated. Patient remained hemodynamically
stable. In the emergency department patient was noted to
have a temperature of 101.9, blood pressure 118/50, heart
rate 119, O2 sat 77%, respiratory rate between 30 and 35.
Patient received sublingual nitroglycerin times one, noted
drop in blood pressure to systolic of 77 over diastolic of
54. Given 5 liters IV fluids. Subsequent ABG of 7.48, 38,
39 in room air. Given 100% nonrebreather and increased O2
sat to 85%. Patient was then electively intubated. Chest
x-ray showed predominantly CHF with bilateral pneumonia
consistent with aspiration pneumonia. Subsequent ABG was
7.36, 45, 96. Patient was put on assist control 14/400, PEEP
12, 100%. Patient was noted to have bloody sputum with
suctioning. No acute GI bleed. Patient received CAT scan of
head which showed no bleed. Patient was subsequently
admitted to the medical ICU. Patient subsequently received
FFP times two units and one bag of platelets.
PAST MEDICAL HISTORY: Head and neck squamous cell cancer in
[**2158**] status post XRT and radical neck dissection. CVA in
[**10-10**]. Recent admission for GI bleed and hemoptysis.
Thrombocytopenia. Ulcerative colitis. Basal cell cancer of
the scalp. Status post head injury in the [**2103**] status post
metal plate insertion.
ALLERGIES: No known drug allergies.
MEDICATIONS: Prednisone taper which ended [**2166-8-3**], Protonix
40 q.day, Fioricet p.r.n., hydrocortisone enema 100 q.h.s.
p.r.n., Colace 100 b.i.d., sulfasalazine 1000 mg t.i.d.
SOCIAL HISTORY: Distant tobacco history. Patient currently
nonsmoker. Nondrinker. Past history of ETOH abuse. No
illicit drugs. Patient recently widowed.
FAMILY HISTORY: Significant for prostate cancer in father
and uterine cancer in sister.
PHYSICAL EXAMINATION: On presentation to medical ICU
temperature was 101.9, pulse 101, blood pressure 116/69,
respiratory rate 12, 96%. Patient was intubated, sedated and
unresponsive. Pupils equal, round, and reactive to light.
Mucous membranes moist. Right IJ placed in E.D. in place.
Regular rate S1, S2, 2/6 systolic ejection murmur. Lungs
showed diffuse crackles with occasional rhonchi. ET tube in
place with some diffuse bloody secretions. Abdomen distended
with decreased bowel sounds. Extremities were warm, 1+
distal pulses, 1+ pitting edema [**1-12**] way up patient's calves.
LABORATORY DATA: Subsequent EKG showed sinus tach at 110, 0
axis, right bundle branch block, slight [**Street Address(2) 4793**] depression in
4 and 5.
HOSPITAL COURSE: The patient was admitted to MICU with the
diagnoses of severe hypoxia, bilateral pneumonia, CHF versus
aspiration pneumonia, resolving hemoptysis, fever and
elevated white count at 21.0. Patient was started on
levofloxacin and Flagyl, pan cultured. Was given propofol
for sedation. Patient's chest x-ray day subsequent to
admission was consistent with aspiration pneumonia. Gram
positive cocci. Was continued on Levaquin and Flagyl.
Vancomycin was added for coverage.
Pulmonary. Bilateral pneumonia persisted right worse than
left. He was continued on Levaquin, Flagyl and vancomycin.
Medical ICU team had difficulty oxygenating patient further
contributing to patient's respiratory failure from aggressive
volume depletion in the emergency department and early ICU
course. Patient was in excess of 18 liters positive.
Patient was placed on assist control, tidal volume 500, PEEP
16, pressure support 25, FIO2 50%. Patient slowly making
gradual decrease in FIO2 to 40%. Patient had decrease in
PEEP to 14. Patient continued on course of antibiotics for
aspiration pneumonia. Patient was noting to continually
desat with decrease in PEEP requiring increase in ventilatory
support. Patient received moderate benefit from aggressive
chest P.T. and recruitment maneuvers. At or around hospital
day 16 patient was switched from assist control to pressure
support of 10, PEEP 16, FIO2 40%. Patient continued to have
thick yellow secretions, coarse breath sounds bilaterally.
Chest x-ray slowly improving. Right interstitial
consolidations. Patient eventually tolerated decrease of
pressure support to 12, PEEP 12, continuing to wean. Patient
was deemed slow to wean from vent settings and ENT was
consulted to do an O.R. trach for patient secondary to
patient's neck dissection and XRT for skin cancer. On or
around [**9-4**] patient was at pressure support of 12,
PEEP 7 [**12-11**], FIO2 40%, remaining extremely sensitive to
changes in pressure support. Drops from pressure support of
14 to 13 would make patient tachypneic pulling low tidal
volumes. Patient remained slow to wean. Patient was
decreased on his sedation of Ativan and fentanyl drips and
slowly began to wean from pressure support of 12 to eventual
goal of pressure support of 8 over a period of 12 days. On
[**2166-9-10**] patient was decreased to pressure support of 8.5 and
40% and was started on trach collar trial for one hour.
Patient continued at pressure support of 8.5 and 40% for
multiple hours without previous tachypnea episodes. Patient
was gotten out of bed to chair and had multiple successful
trach collar trials ranging from 15 minutes to 1 1/2 hours.
Patient was aggressively diuresed with Lasix with a goal of
0.5 to 1 liter net negative on fluid balance per day.
Diuresis was somewhat limited secondary to recurrent bouts of
hypotension with systolic in the 90s, thus delaying diuresis.
Over the course of the hospital stay from [**8-12**] to
today, [**9-12**], patient is now net only 1.5 liters positive
in fluids and responding to Lasix.
Infectious disease. Throughout his hospital course patient
continued to have low grade fevers in the range from 100 to
101.0. Patient occasionally spiked fevers as high as 102.8.
Patient was put on ceftriaxone and vancomycin. Patient's
white counts were in the high teens and subsequently
decreased. All cultures, blood and urine, were negative.
Further all cath tips sent for culture were negative.
Patient was given abdominal CT and sinus CT to look for
source. Sinus CT was positive for right maxillary sinusitis.
Abdominal CT was negative for infectious source. Patient was
continued on antibiotics. ENT was consulted for sinusitis
and suggested increase head of bed, intranasal spray, no
acute management necessary at this time. On or around
[**9-2**] patient was found to be C.diff positive in the
stool. Patient was started on Flagyl. All blood cultures,
wound cultures and sputum cultures remained negative.
Patient without any new elevations in white count or
temperature spikes for the 10 days prior to discharge.
Patient's hematocrit ranged from the high 20s in the
beginning of his hospital stay and began to very slowly drift
down throughout the hospital course. Patient had no source
of obvious bleeding, although he was noted to have OB
positive stool. Patient was transfused two units of blood
with an inappropriate bump in patient's hematocrit.
Patient's hematocrit only increased from 23 to 25 status post
two units. Patient's hematocrit tended to be stable with
slight decrease. Patient eventually trended down from
hematocrit of 26 to a slow decrease over subsequent days to
hematocrit of 23. Patient was transfused two additional
units of blood, bringing patient's hematocrit to an
appropriate bump. Patient's hematocrit was noted to be 31.
From [**2166-9-3**] patient's hematocrit has remained around 31 and
remained stable. No active bleeding prior or since noted.
Neurologically despite negative head CT in the emergency
department, throughout patient's course with decreasing
sedation, patient continued to not move any extremities. Did
appear to track and somewhat understand responses, although
he was nonvocal in response. ICU staff remained concerned
while sedation was completely turned off for a period of four
days on or about [**9-1**]. Patient was given repeat head CT
which was negative for bleed. Approximately four days after
shutting off sedation patient was noted to move all
extremities, although was noted to be weak. Subsequent day
patient was found to be able to follow simple commands,
squeezing hands, blinking eyes, etc.
Trach done in O.R. was done on [**9-1**]. Patient was
also sent to interventional radiology on [**9-5**] to receive a
PEJ, percutaneous jejunal tube, for nutritional support.
Prior patient had been on a combination of TPN and tube
feeds. At time of discharge on [**2166-9-12**] patient currently has
a left subclavian day seven and previously described PEJ tube
also day seven. Both insertion sites are clean, dry and
intact and devoid of any signs of infection. Throughout
patient's course he was kept on prophylaxis including
pneumoboots, subcu heparin and Prevacid. Patient currently
taking Colace, erythromycin eyedrops, Reglan, Gas-X, Flagyl
day seven, lactulose, miconazole cream, Ativan, fentanyl
patch and Ambien.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 39096**]
Dictated By:[**Last Name (NamePattern1) 43678**]
MEDQUIST36
D: [**2166-9-12**] 11:43
T: [**2166-9-12**] 12:24
JOB#: [**Job Number **]
ICD9 Codes: 5070, 4280, 2765, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4521
} | Medical Text: Admission Date: [**2113-7-12**] Discharge Date: [**2113-7-18**]
Date of Birth: [**2113-7-12**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is an 1,195 gm product of a
27 and 6/7 weeks twin gestation born to a 25-year-old G 4, P
3 woman whose pregnancy was uncomplicated until four days
prior to delivery when she experienced preterm labor followed
by vaginal spotting. She was transferred to [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for further treatment. She was
treated with betamethasone, ampicillin and Flagyl. She
received one dose of betamethasone and had rupture of
membranes just before delivery. There was a cesarean section
because of breech positioning of twin A. Her prenatal screens
were O positive, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, unknown GBS and rubella
immune. At delivery, this twin was vigorous, given blow-by
and stem. Apgars were seven and eight. He had mild grunting,
flaring and retracting. He was brought down to the Neonatal
Intensive Care Unit. At that time, he was intubated and given
surfactant.
PHYSICAL EXAMINATION: His weight was 1,195 gm. In general,
he was pink, active and nondysmorphic. He was well saturated
with blow-by. He had significant bruising on his left elbow
and right flank. He had moderate retractions with equal air
entry. His heart was regular rate and rhythm without murmurs.
Abdomen was benign. Neurologically, he was normal for his
age. His hips were normal.
HOSPITAL COURSE: Respiratory: Initially, the infant was
intubated and given surfactant twice. He weaned quickly to
the next day to CPAP and then quickly weaned to room air by
day of life two. He was started on caffeine for apneic
spells, which have been mild in number and severity. He
continues on room air with 3-4 apneic and bradycardiac spells
a day. He remains on caffeine.
Cardiovascularly, initially there was no murmur heard. He had
a murmur heard on day of life five and because of the
metabolic acidosis, he had an echocardiogram at this time
which showed a small patent ductus arteriosis without any
shunting. It was felt that it was not necessary to treat him.
We have just been following him clinically. His blood
pressures have been stable and there have been no other
concerns.
Fluids, electrolytes and nutrition: He was made NPO
initially and started on D10W. He was started on parenteral
nutrition on his second day of life. He initially started on
feeds on day of life three and he advanced slowly, but he was
made NPO over the weekend with a significant metabolic
acidosis. He just restarted feeds on day of life six and it
will be advancing slowly. His weight today is 1,080 gm.
Electrolytes have been stable throughout his hospital course.
Hematology: He has had hyperbilirubinemia and been on and
off phototherapy. Currently, he is off phototherapy and will
have a follow-up bilirubin tomorrow.
Infectious Disease: Initially, he was started on ampicillin
and gentamycin for two days. After his blood cultures were
negative for 48 hours, the antibiotics were discontinued. He
has no other symptoms of infection.
Neurology: He is scheduled to have an initial head
ultrasound on day of life eight and will then, if everything
goes well, have another one on day of life thirty.
INTERIM DIAGNOSES: Prematurity, RDS, hyperbilirubinemia,
rule out sepsis.
DR [**First Name8 (NamePattern2) 37693**] [**Last Name (NamePattern1) 37692**] 50.454
Dictated By:[**Last Name (NamePattern1) 58225**]
MEDQUIST36
D: [**2113-7-18**] 16:20:43
T: [**2113-7-18**] 16:58:01
Job#: [**Job Number 58226**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4522
} | Medical Text: Admission Date: [**2171-2-16**] Discharge Date: [**2171-3-6**]
Date of Birth: [**2101-3-25**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a very pleasant
68-year-old gentleman, who reports that he was sitting in a
chair at 9:30 on the morning of admission when he developed
the most severe headache of his life. The headache was
global and resulted in immediate nausea and vomiting. He
also notes pain as well as neck stiffness and light
sensitivity. Both he and his son also noticed some drooping
on the left side of the face. Otherwise, he has had no
difficulties in speech or weakness in his arms or legs. He
has had no previous episodes of weakness in the past. He was
then transferred via Life Flight to [**Hospital1 190**].
PAST MEDICAL HISTORY: Unremarkable. He denies MI, stroke,
diabetes, or hypertension.
CURRENT MEDICATIONS: None.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Unremarkable.
PHYSICAL EXAMINATION: He was afebrile, heart rate was 69,
blood pressure was 161/91, respiratory rate 18, and 98%. He
was alert and oriented times three. He answered all
questions appropriately. His pupils were 4 to 2 mm reactive
bilaterally. Face shows a slight left asymmetry, but his
smile was generally equal. Extraocular movements were
intact. He blinks to threat bilaterally. Shoulder shrugs
were equal. Grips were equal bilaterally. He had no
pronator drift. IP was [**3-25**] on the right and [**4-24**] on the left.
Gastrocs, [**Last Name (un) 938**], AT were 4+/5 bilaterally. He had downgoing
toes bilaterally. Heart showed regular rate, no murmurs.
Lungs are clear to auscultation. Abdomen was soft and
nontender.
LABORATORIES: His white count was 10.6, hematocrit 39.5,
platelets 215. Electrolytes showed a sodium of 138,
potassium 3.4, chloride 104, bicarb 27, BUN 10, creatinine
0.7, glucose was 216. Calcium was 8.2, magnesium 2.0,
phosphorus 2.4. PT 13.1, PTT 25, and INR was 1.1.
He did have a CAT scan, which showed a significant
subarachnoid hemorrhage.
HOSPITAL COURSE: He was admitted and had a right frontal
ventriculostomy drain placed at the bedside. At 8 p.m. on
the night of admission, he did undergo an angiogram, which
did not reveal an aneurysm. He was then closely monitored in
the Intensive Care Unit.
He continued to complain of his headache. He required a
Nipride drip for blood pressure control. He was placed on
antibiotics while the drain was in place. He was also loaded
with Dilantin for seizure prophylaxis post angiogram. He had
no groin hematoma and did have a positive pulse in the right
lower extremity. He was closely monitored in the Intensive
Care Unit. He had a repeat head CT on [**2-17**], which
was unchanged. It was also recommended that he have a MRI
with gadolinium of the cervical spine to rule out any
vascular malformations. This was done and was negative.
He was on nimodipine for vasospasm prophylaxis. On [**2-20**], it was noted that his serum sodium started to drift
downward. He continued to be neurologically stable and the
sodium was repleted with 3% IV solution. The drain after the
first week in the hospital, he had no seizures, so the
Dilantin was discontinued. The drain height was gradually
raised and he tolerated this well.
He underwent a second angiogram on [**2-21**], which once
again showed no aneurysm or source of bleeding. His blood
sugars were elevated from the time of admission and he was
controlled with insulin on sliding scale dosage. His diet
was advanced, but he did have a 750 cc fluid restriction for
his hyponatremia. His ventriculostomy drain was clamped on
[**2-21**] as this caused some leaking at the tube site, it
was pulled to avoid backflow and chance of infection.
Patient continued to be monitored in the Intensive Care Unit
for his hyponatremia, which did get as low as 129. On [**2-22**], he did continue to complain of headaches, though these
did slowly subside over the course of the admission.
Monitored with CAT scans of the head, which showed some
persistent fluid collection in the left frontal-parietal
region, but was otherwise unchanged.
An Endocrine consult was obtained on [**2171-2-26**] for his
continued hyponatremia and elevated glucoses. Their
recommendations included salt tablets up to 5 grams 3x/day
with the addition of Lasix as well as NPH insulin twice per
day with sliding scale doses as needed. Patient was able to
be transferred out of the unit to the floor on [**2-27**].
His sodium did stabilize on the salt tablets, but he
continued to be monitored daily. His blood glucoses also got
in better control, and he is being education on self dosing.
He did have a lumbar puncture performed on [**3-1**] that
did show an opening pressure of 29. A repeat lumbar puncture
on [**3-3**], which showed an opening pressure of 7.
His steroids were tapered. He had a third LP performed on
[**3-5**], which showed an opening pressure of 14, which was
within acceptable range, and he did not meet consideration of
a shunt.
The plan for the patient is to be discharged to home, where
he will need visiting nurse help with his insulin injections,
blood draws to check his sodium level every other day. He
will also be tapered off of his steroids.
MEDICATIONS ON DISCHARGE:
1. Dexamethasone in a tapering dose.
2. Insulin NPH b.i.d. and regular sliding scale.
3. Lasix.
4. Metoprolol.
5. Sodium chloride tablets.
6. Lansoprazole.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 53090**]
MEDQUIST36
D: [**2171-3-5**] 11:56
T: [**2171-3-5**] 11:53
JOB#: [**Job Number 53091**]
(cclist)
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4523
} | Medical Text: Admission Date: [**2185-1-3**] Discharge Date: [**2185-1-15**]
Date of Birth: [**2124-7-21**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 60-year-old male
with metastatic melanoma, admitted to begin cycle 1, week 1
high-dose IL-2 therapy. His oncologic history began in [**2184-7-27**], when he noted a right groin skin tag which grew quickly
over 2 months. Excisional biopsy in [**2184-10-27**] revealed a
greater than 11 mm thick, ulcerated melanoma with perineural
invasion and mitotic rate of 8 per meters squared. He was
referred to Cutaneous [**Hospital **] Clinic, at which point 2
subcutaneous nodules along the right groin scar were noted
and a left posterior shoulder subcutaneous nodule was noted.
Fine needle aspiration confirmed a melanoma at the site. PET
CT revealed widespread metastases in the lung, liver,
subcutaneous tissues and bone. Brain MRI was negative. He was
evaluated for high-dose IL-2 and passed eligibility testing
to begin therapy.
PAST MEDICAL HISTORY: BPH, status post laparoscopic
cholecystectomy in [**2178**], left knee arthroscopic surgery
complicated by left DVT, hypertension, sleep apnea,
osteoarthritis of the right knee, melanoma as above, benign
positional vertigo, history of pseudogout, history of C-7
narrowing with occasional nerve pain.
ALLERGIES: No known drug allergies.
MEDICATIONS: Lisinopril 20 mg daily, on hold, Flomax 0.4 mg
daily, Proscar 5 mg daily, Naprosyn 500 daily to b.i.d.
p.r.n.
PHYSICAL EXAMINATION: GENERAL: Well-appearing male in no
acute distress. Performance status 1. VITAL SIGNS: 97.5, 130,
18, 133/80, O2 saturation 94% in room air. HEENT:
Normocephalic, atraumatic. Sclerae anicteric. Moist oral
mucosa without lesions, multiple scalp nodules present. NECK:
Supple. LYMPH NODES: No cervical, supraclavicular, bilateral
axillary or bilateral inguinal lymphadenopathy. Right groin
subcutaneous nodules noted. HEART: Regular rate and rhythm,
S1 and S2. CHEST: Clear to percussion and auscultation
bilaterally. ABDOMEN: Rounded, positive bowel sounds, soft,
nontender, no HSM or masses. EXTREMITIES: No lower extremity
edema. NEURO EXAM: Nonfocal. SKIN: Right groin biopsy site
healed without nodularity. There are subcutaneous nodules
above and below the biopsy site as well as scattered scalp
nodules. There is a left shoulder subcutaneous nodule
measuring approximately 4 x 3 cm and a left low axillary
chest wall subcutaneously nodule measuring approximately 1
cm.
ADMISSION LABS: WBC 10.6, hemoglobin 11.7, hematocrit 34.5,
platelet count 237,000, INR 1.2, BUN 20, creatinine 1, sodium
138, potassium 4.5, chloride 99, CO2 24, glucose 138, ALT 40,
AST 41, LDH 970, alkaline phosphatase 179, amylase 35, total
bilirubin 0.8, lipase 39, albumin 3.8, calcium 9.3,
phosphorus 3.6, magnesium 2.3.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted and underwent
central line placement to begin therapy. His admission weight
was 106.6 kg, and he received interleukin-II 600,000
international units per kilogram, equaling 64 million units
IV q.8h. x14 potential doses. During this week, he received
10 of 14 doses, with 1 dose held for questionable
neurotoxicity and 3 doses held due to development of
tachypnea, stridor and respiratory distress, requiring
mechanical ventilation. This event occurred in early morning
hours of treatment day #5 and he was transferred emergently
to the ICU and intubated, given stridor and tachypnea. He was
not having significant hypoxia at this time. He then became
hypotensive, requiring initiation of phenylephrine and
Levophed. At the time of his intubation, his bicarbonate was
15 and he was aggressively treated with bicarbonate
repletion. The patient was intubated x4 days and was
eventually extubated on [**1-11**]. He continued to recover
and was recovering was transferred back to the floor on
[**1-12**], where rehab was initiated. He developed
Clostridium difficile diarrhea, improved on Flagyl. He was
eventually discharged to home on [**2185-1-15**] with
physical therapy.
Other side effects during IL-2 therapy included mild chills;
development of an erythematous skin rash; nausea, improved
with lorazepam; diarrhea, improved with Lomotil, and fatigue
During this week, he developed acute renal failure with a
peak creatinine of 7.3, improved to 1.3 at the time of
discharge. He developed hyperbilirubinemia with a peak
bilirubin of 7.1, improved to 1.1 upon discharge. He also
developed transaminitis with a peak ALT of 100 and peak AST
of 117, improved to within normal limits at the time of
discharge. He was anemic with hemoglobin of 7.2, improved to
11.7 after packed red blood cell transfusion. He was
thrombocytopenic with a platelet count low of 55,000, without
evidence of bleeding. As noted above, he developed metabolic
acidosis, felt to be at least partially responsible for his
respiratory failure, with a minimum bicarbonate of 14,
improved with bicarbonate repletion. He had no evidence of
coagulopathy or myocarditis. By [**2185-1-15**] he was
discharged to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Metastatic melanoma, status post cycle
1, week 1 high-dose IL-2 complicated by respiratory failure
and acute renal failure.
DISCHARGE MEDICATIONS: Lorazepam 1 mg q.4-6h. p.r.n.
nausea/vomiting, Compazine 10 mg q.6h. p.r.n.
nausea/vomiting, Proscar 5 mg daily, Flagyl 500 mg p.o.
t.i.d. oxycodone 5 to 10 mg q.4h. p.r.n. pain, Zantac 150 mg
p.o. t.i.d.
FOLLOWUP PLANS: Mr. [**Known lastname **] will be seen in clinic in 1 week
and the 2nd week of IL-2 therapy will be determined at that
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 26819**], [**MD Number(1) 26820**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2185-4-1**] 16:17:52
T: [**2185-4-3**] 09:22:18
Job#: [**Job Number 69910**]
cc:[**Numeric Identifier 69911**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29848**], MD
[**First Name (Titles) **] [**Last Name (Titles) 159**] Associates
50 [**Location (un) 69912**], [**Numeric Identifier 43858**]
ICD9 Codes: 2762, 5845, 2767, 4280, 2760, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4524
} | Medical Text: Admission Date: [**2172-9-29**] Discharge Date: [**2172-10-3**]
Date of Birth: [**2086-4-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 86-yo cantonese speaking male who presents
from his nursing home after an episode ofacute shorntess of
breath and neurological changes. He has chronic lung disease on
home 2L nc home o2. Vitals on the scene were hr 100, bp 119/68
and o2 83 on 2L. Glucose 173. According to the Neurology
consult service who spoke with the NH, "he was seen walking the
halls around 8:30am, and was noted to be able to eat his
breakfast without difficulty. He then went back to his room
where they helped him shower and shave and he went back to bed.
Somewhere between 10:30 and 11am he was found in his room,
lethargic and 'grey'. He was found at that time to have an SaO2
of 83% on 2L NC, which only improved to 91% with 5L NC. He was
also tachypnic to 22, hypotensive to 80/50 and tachycardic to
110." A cantonese speaking nurse reported that he "was slow to
respond, and was soft spoken, but was able to provide
appropriate responses."
.
On arrival to the ED he was hypoxic to 88% on RA and his
systolic pressure in 80s. He was noted to be minimally
responsive, with a question of possible decreased movement on
his right side. A code stroke was called.
.
A CTA of the head and neck and a CT brain perfusion were
negative. He was persistently hypotensive and a central line was
placed and norepi started. A formal ECHO did was not concerning
for cardiogenic shock or right heart strain so a CTA was not
obtained for r/o PE. He was treated with vanc and zosyn for PNA
but vanc was stopped for red man syndrome.
.
On arrival, his son was interviewed with the interpreter. Per
the son, in the several days prior he had been complaining of
palpitations. However, when asked if he had chest pain, the son
stated that he actually had chest pain and not palpitations. The
son denies any cough or increased sputum.
Past Medical History:
COPD, HTN, DM, PE s/p IVC filter, hearing loss BL, dementia
Social History:
Was at the rehab prior to transfer here.
Before rehab, was living at home with wife
[**Name (NI) **]: [**Name (NI) 951**] listed as contact and HCP
Family History:
NC
Physical Exam:
Physical Exam on Arrival to the MICU
General Appearance: No acute distress, Thin
HEENT: PERRL, Normocephalic
CV: normal S1 and S2, no m/r/g
Resp: rhonchorous
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no edema, cyanosis, or clubbing, no edema
MSK: + muscle wasting, unable to stand
Skin: warm, no rash or jaundice
Physical Exam on Discharge from the MICU
General: alert, awake, answering questions appropriately
CV: RRR, no m/r/g
Resp: diminished movements in the bases, continues to have
crackles in the bases, more on the right, occasional inspiratory
wheeze on the left
Abd: soft, NT, ND, BS+
Extremities: warm, dry, no edema
Pertinent Results:
[**2172-9-29**] 01:30PM BLOOD Neuts-84.0* Lymphs-11.0* Monos-3.4
Eos-1.0 Baso-0.6
[**2172-9-29**] 01:30PM BLOOD WBC-9.7 RBC-4.60 Hgb-13.9*# Hct-42.9#
MCV-93 MCH-30.3 MCHC-32.5 RDW-16.5* Plt Ct-406
[**2172-9-29**] 01:30PM BLOOD PT-12.7 PTT-21.6* INR(PT)-1.1
[**2172-9-29**] 09:00PM BLOOD Glucose-42* UreaN-15 Creat-0.6 Na-144
K-3.7 Cl-108 HCO3-28 AnGap-12
[**2172-9-30**] 05:48AM BLOOD ALT-10 AST-13 CK(CPK)-46* AlkPhos-67
TotBili-0.3
[**2172-9-29**] 01:30PM BLOOD proBNP-1384*
[**2172-9-29**] 01:30PM BLOOD cTropnT-<0.01
[**2172-9-30**] 05:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2172-9-29**] 01:30PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5
[**2172-9-30**] 05:48AM BLOOD Albumin-3.0* Calcium-7.5* Phos-3.6 Mg-2.1
[**2172-9-29**] 04:52PM BLOOD Type-[**Last Name (un) **] pO2-50* pCO2-42 pH-7.38
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2172-9-29**] 09:37PM BLOOD Type-MIX Temp-35.7 pO2-104 pCO2-54*
pH-7.33* calTCO2-30 Base XS-0 Intubat-NOT INTUBA Comment-GREEN
TOP
[**2172-9-29**] 01:45PM BLOOD Glucose-132* Lactate-2.7* Na-142 K-4.4
Cl-101 calHCO3-29
[**2172-9-29**] 09:37PM BLOOD Lactate-1.0
[**2172-9-30**] 05:48AM BLOOD WBC-11.3* RBC-4.30* Hgb-12.9* Hct-40.1
MCV-93 MCH-30.1 MCHC-32.2 RDW-16.3* Plt Ct-379
[**2172-9-29**] 05:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2172-9-29**] Urine legionella antigen negative
[**2172-9-29**]
CT/CTA Head/Neck:
FINDINGS:
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
large areas of edema, large masses, or mass effect. There is
preservation of normal [**Doctor Last Name 352**]-white matter differentiation.
Prominence of the ventricles and sulci is consistent with
age-related parenchymal atrophy. Incidental note is made of
cavum septum pellucidum, et vergae variant. The paranasal
sinuses and mastoid air cells are clear, although there is
under-pneumatization of the left mastoid air cells. Soft tissues
of the orbits are within normal limits.
CT PERFUSION: The mean transit time, cerebral blood flow, and
cerebral blood volume are within normal limits with no evidence
of perfusion abnormality to suggest infarct.
CTA HEAD: There is prominent calcified atherosclerotic disease
of the
cavernous portion of the left internal carotid artery likely
causing some
degree of narrowing, although the full extent is difficult to
appreciate given the extensive calcification. Milder calcified
atherosclerotic disease is noted of the right cavernous ICA.
Otherwise, there are no areas of significant stenosis,
occlusion, or aneurysm formation measuring more than 2 mm. There
is also calcified atherosclerotic disease of the intracranial
portion of the vertebral arteries bilaterally without
significant stenosis.
CTA NECK: There is extensive severe atherosclerotic disease with
diffuse
areas of ulcerative plaque noted within the aortic arch, similar
in appearance to the CTA chest of [**2172-6-29**]. Extensive
atherosclerotic disease causes severe stenosis at the origin of
the left common carotid artery and also severe stenosis at the
origin of the left subclavian artery. The right common carotid
artery demonstrates calcified atherosclerotic disease proximally
but without significant stenosis. The right cervical internal
carotid artery demonstrates a minimal diameter of
7.0 mm proximally and 4.0 mm distally. The left cervical ICA
demonstrates a minimal diameter of 6.5 mm proximally and 3.5 mm
distally.
The proximal left vertebral artery is occluded. There is poor
reconstitution within the mid left vertebral artery, although
adequate flow is seen in the distal artery beginning around the
level of vertebral body C3. However, the direction of flow
cannot be assessed on CTA.
CT Chest
There is severe emphysema. Patchy opacities are noted within the
left upper lobe concerning for aspiration and/or pneumonia.
Although not visualized on the axial CT portion, the coronal
scout image also demonstrates areas of patchy opacity in the mid
right lung.
IMPRESSION:
1. No acute intracranial process. No areas of perfusion
abnormality to
suggest infarct.
2. Severe extensive atherosclerotic disease with diffuse
ulcerative plaque
within the aortic arch extending to the proximal great vessels
with severe
stenosis at the origin of the left common carotid artery and
severe stenosis at the origin of the left subclavian artery. The
proximal left vertebral artery is occluded but reconstitutes
fully distally at the level of the vertebral body C3. The
direction of flow cannot be determined on CTA. There is also
narrowing of the origin of the right vertebral artery.
3. Extensive calcified plaque of the cavernous portion of the
left ICA with some degree of narrowing. However, it is difficult
to characterize the degree of stenosis due to the extent of the
calcification.
4. Severe emphysema with patchy opacities in the visualized left
upper lobe and right mid lung, concerning for pneumonia and/or
aspiration. Please refer to same day chest x-ray for further
details.
[**2172-10-1**]
Video oropharyngeal swallowing study:
FINDINGS: There was penetration and aspiration of thin liquids.
There was
penetration with nectar-thick liquids with independent cough
reflex which
cleared the nectar preventing aspiration.
IMPRESSION: Aspiration of thin liquids and penetration of
nectar-thick barium with independent cough reflex. For further
details, please refer to speech and swallow division note in
OMR.
Brief Hospital Course:
86yo M with h/o not clearly defined chronic lung disease
presenting with acute onset hypoxemia and hypotension.
# Hypoxemia. Most likely [**1-22**] aspiration pneumonia/pneumonitis
given acute presentation and as suggested by CTA chest. PE was
ruled out with CTA of the chest. Patient was kept NPO. Given
he was in the rehab, patient was started with broad spectrum
antibiotics, including vanc, zosyn, and levofloxacin.
Levofloxacin was discontinued as urine legionella was negative.
Given his clinical improvement with supportive care such as nebs
and chest PT, antibiotics was narrowed to cover gram
negatives/anaerobes with Unasyn only and vancomycin for positive
MRSA swab. Speech and swallow confirmed presence of aspiration
and recommended dysphagia pureed diet with nectar thick liquid.
Family meeting was held with the patient's family (son)
regarding his prognosis and the cause of his frequent
respiratory distress. It was clearly stated by the son that the
patient enjoys eating and would not want to have any type of
tube feeding understanding that tube feeding would not eliminate
future aspiration. His O2 supplement was unable to be weaned
below 40% face tent and 4L NC to maintain O2Sat > 90%. Baseline
O2 supplement was 2L NC. Chest PT may be helpful. Continue
antibiotics and nebulizers prn with home meds.
# Hypotension. Most likely sepsis vs. distributive [**1-22**]
pneumonitis. Unlikely cardiogenic given echocardiogram and
exam. Levophed was weaned on HD2. Lactate normalized.
Resolved yoib discharge.
# Altered mental status. CT head without new changes other than
significant atherosclerotic changes. Consistent with delirium,
enecephalopathy from hypoxemia, hypotyension. It resolved and
improved to baseline per family.
# COPD. By imaging. Patient was placed on scheduled
nebulizers. No steroid was given as it was not consistent with
COPD exacerbation. He should continue with nebulizers until
oxygen supplement improves.
# DM2. Metformin was held while in the hospital. He was on
insulin sliding scale
# Access: left PICC line
Transitional issue:
[] Chest PT
[] Physical Therapy
[] O2 supplement
[] vancomycin trough before the 4th dose on [**2172-10-4**].
[] discussion with family regarding "Do Not Rehospitalize" +/-
Hospice given
[] Outpatient PCP follow up upon discharge from LTAC
Medications on Admission:
humalog insulin sliding scale 151-200: 2units, 201-300
Lasix 20mg po daily
spiriva
lidoderm patch [**12-22**] patch to each side of each ankle daily (2
patches)
advair 100-50
docusate [**Hospital1 **]
metformin 500 [**Hospital1 **]
senna 2 tabs [**Hospital1 **]
vit d 400 units [**Hospital1 **]
dulcolax supp prn
fleet enema prn
tylenol prn
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit/ml Injection TID (3 times a day).
2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Humalog Insulin Sliding Scale
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB or wheeze.
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
7. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**12-22**]
patch Topical once a day: to each side of each ankle. 2 patches
.
8. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
9. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
10. senna 8.6 mg Capsule Sig: Two (2) Capsule PO twice a day as
needed for constipation.
11. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
12. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. Ampicillin-Sulbactam 1.5 g IV Q6H
Day 1 = [**9-30**]
15. Vancomycin 1000 mg IV Q 24H
16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchy back.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Oxygen
Titrate oxygen to O2 Sat greater than 91%.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
- Hypoxemia and Hypotension secondary to Aspiration pneumonia
- Delirium, resolved
Secondary diagnoses:
- Type 2 Diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to take care of you while at [**Hospital1 771**].
You were admitted because of trouble breathing and low blood
pressure. Your labs did not injury to your heart muscle.
However, your chest films have showed new areas of infection and
inflammation. You are on antibiotics to treat this. We have
found that these areas are likely from aspiration of the food
that you eat. Speech and Swallow specialists have recommended
you to be on a pureed diet and nectar thickened fluid to
prevent. However, even with these modification, aspiration can
still occur. After speaking with your family, we understand
that you would not want to have any feeding tube. It will be
important for you to speak with your family about whether you
want to return to the hospital in the future if the same
symptoms occur.
Your CT head showed that you have significant atherosclerotic
disease in your blood vessels. However, there is no bleeding in
your head. The confusion that you had initially is probably due
to the underlying infection.
Please note the changes of medications below.
- Start vancomycin until [**2172-10-7**] to complete total of 8 days
- Start Unasyn until [**2172-10-7**] to complete total of 8 days
- Start albuterol nebulizer every 6 hours as needed for
shortness of breath or wheeze
- Start ipratropium nebulizer every 6 hours as needed for
shortness of breath or wheeze
- Start heparin 5000 units subcutaneously three times a day for
deep vein thrombosis prophylaxis
- Sarna lotion was started for you for dry itchy back.
Followup Instructions:
Follow up with primary care provider upon discharge from the
LTAC
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2172-10-4**]
ICD9 Codes: 5070, 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4525
} | Medical Text: Admission Date: [**2141-3-24**] Discharge Date: [**2141-4-1**]
Date of Birth: [**2065-9-26**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Codeine / Ticlid / Atorvastatin /
Lipitor / Crestor
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
worsening shortness of breath, paroxysmal nocturnal dyspnea,
non-productive cough, chest pressure
Major Surgical or Invasive Procedure:
none this admission
[**2141-3-15**]
Video-assisted thoracoscopic left lower lobe wedge resection and
mediastinal lymph node dissection.
History of Present Illness:
75 year old female s/p LLL wedge with pathology revealing
moderately-differentiated squamous cell carcinoma without nodal
involvement and negative margins (T1No- stage 1A), with 3 day
history of worsening SOB after discharge; accompanied with
unchanged non-productive cough, complaints of chest pressure,
and PND. She was admitted back to Thoracic surgery service for
atrial fibrillation and workup of shortness of breath.
Past Medical History:
CAD s/p CABG [**2117**], stents [**2128**], [**2134**]
HTN
COPD
bilateral renal artery stenosis s/p right stent placed [**11-28**]
thoracic aortic aneurysm medically managed
atrial fibrillation
anxiety
Barrett's esophagus seen on last EGD [**2134**]- but not on bx
s/p cholecystectomy
s/p appendectomy
s/p oophrectomy
h/o GIB- 2yr ago, EGD/colonoscopy at OSH
Social History:
- lives alone
- tobacco: current smoker, 60pk-yr history
- EtOH: denies
Family History:
mother, grandmother - liver cancer
Physical Exam:
Vitals: T: 96.9 degrees Fahrenheit, BP: 132/44 mmHg supine, HR
132 AF bpm, RR 22 bpm, O2: 98% on 4L NC.
Gen: Pleasant, well appearing.
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RRR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-26**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2141-3-24**] 05:30PM PT-13.1 PTT-30.3 INR(PT)-1.1
[**2141-3-24**] 05:30PM PLT COUNT-281
[**2141-3-24**] 05:30PM NEUTS-78.6* LYMPHS-16.9* MONOS-3.5 EOS-0.7
BASOS-0.3
[**2141-3-24**] 05:30PM WBC-7.1 RBC-3.10* HGB-9.9* HCT-29.4* MCV-95
MCH-32.0 MCHC-33.8 RDW-25.9*
[**2141-3-24**] 05:30PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2141-3-24**] 05:30PM proBNP-8256*
[**2141-3-24**] 05:30PM cTropnT-<0.01
[**2141-3-24**] 05:30PM estGFR-Using this
[**2141-3-24**] 05:30PM GLUCOSE-87 UREA N-31* CREAT-0.9 SODIUM-141
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2141-3-24**] 05:54PM GLUCOSE-84 LACTATE-1.6 NA+-140 K+-4.7 CL--106
TCO2-23
[**2141-3-24**] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2141-3-24**] 09:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
Brief Hospital Course:
Ms. [**Known lastname 784**] was admitted to the Thoracic surgery service on
[**2141-3-24**] for CHF exacerbation and atrial fibrillation with RVR.
.
She was diuresed with lasix, given lopressor IV, and started on
a diltiazem drip on day 1, which did not quiese her atrial
fibrillation. Day 2 she was bolused and started on amiodarone
drip; which unfortunately did not stop her afib with RVR
120's-140's. The patient remained hemodynamically stable. A TEE
was ordered and cardiology consult obtained on [**2141-3-27**]. CTA was
done on [**2141-3-26**] ruling out pulmonary embolism. Serial cardiac
enzymes were negative. The patient remained short of breath, and
given her uncontrolled afib; stayed in the ICU for observation
and management.
.
Patient was transferred to [**Hospital Unit Name 196**] for further management of the
following:
.
#. Afib: Patient underwent TEE/cardioversion on [**3-29**]. She
remained in sinus rhythm subsequently and started amiodarone
400mg daily. She was started on coumadin with heparin bridge.
Patient then switched to lovenox bridge (which was stopped after
hct drop-see below) and d/c'd on coumadin 2 mg daily. Her
outpatient cardiologist was contact[**Name (NI) **]. [**Name2 (NI) **] has history of
stable aortic ulcer, per outpatient cardiologist. She agrees
with anticoagulation given risk of embolic event and will follow
up her INR. Coumadin may be stopped after 1 month, if there are
further concerns for bleeding. Patient should be continued on
amiodarone 400mg daily for 1 month, then 200mg daily.
- INR check by VNA, goal 2-2.5. Followed by outpatient
cardiologist.
- Continue coumadin for at least 1month
- Amlodipine 400mg x1month, then 200mg daily
.
#. Pump: An echo done [**3-27**] showed EF 45% and on TEE [**3-30**] EF
was 55%. She was diuresed as needed with iv lasix 20mg prn, and
continued on her ace-i and beta-blocker. She was discharged
home on lasix 20mg po daily.
- Electrolyte check by VNA. Followed by outpatient cardiologist.
.
#. CAD: Known CABG and PCI in the past. She was continued on
beta-blocker, ace-inhibitor, aspirin and statin.
.
#. UTI: Patient was treated w/ cefpodoxime for ecoli/klebsiella
UTI.
.
#. Anemia: Patient had a hct drop on [**3-31**], to 19.9. Repeat hct
was 26. Her lovenox was stopped. She had several episodes of
small amount of hemoptysis. A CXR was taken and was relatively
unchanged. CT surgery evaluated patient and did not think that
her hemoptysis was significant.
- Hct check by VNA.
.
#. SCC: s/p lung resection. Continued nebs, guaifenisin.
Medications on Admission:
ASA 325mg
simvastatin 80mg
Metoprolol Succinate 50 mg
Sustained Release 24 hr
Amlodipine 10mg
Lisinopril 20mg
Singulair 10mg
Advair 100/50
Pantoprazole 40mg
Tramadol 50q6hp
APAP 325-650 q6h prn
guaiafension 100/5 [**4-3**] mlq6h
Acetylcysteine 20 % (200 mg/mL) 3 ML q6h
Xopenex 1.25/3 1 mL q8h prn
Ativan 0.5mg prn
hydroxyurea 500mg
Atrovent [**11-26**] neb INH q6h prn
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
7. Hydrea 500 mg Capsule Sig: One (1) Capsule PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. Home Oxygen
Please set up home oxygen to maintain O2 sats >92
10. Outpatient Lab Work
* Please check INR Monday, Wednesday, Friday ([**2143-4-4**], 14)
and fax to [**Telephone/Fax (1) 41857**], Attention Dr. [**Last Name (STitle) 41858**].
* Please check hematocrit, potassium, and creatine Monday [**4-3**]
and fax to above number.
11. Amiodarone 200 mg Tablet Sig: 1-2 Tablets PO once a day:
400mg (2 tablets) once a day for 1month. Then take 200mg (1
tablet) once a day after that.
Disp:*60 Tablet(s)* Refills:*2*
12. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-26**]
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*1*
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
17. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
18. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial fibrillation with RVR
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires [**Company 11807**] or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for your shortness of breath.
You were found to have a very fast irregular heart rate, atrial
fibrillation. You underwent cardioversion to convert your hear
into a normal rhythm. You tolerated this procedure well.
We have made the following changes to your medications:
1. Amiodarone 400mg for 1month then take 200mg after 1month to
maintain you in normal heart rhythm.
2. Metoprolol 50mg daily for blood pressure and heart rate
control.
3. Coumadin 2 daily to prevent clot formation. You should be on
this for at least 1month, you can discuss with Dr. [**Last Name (STitle) **] when
to come off of this medication.
4. Stop Amlodipine.
5. Decreased Zocor dose to 20mg daily. Amiodarone interacts with
zocor, you should only take 20mg zocor while you are on
amiodarone.
6. Start Atrovant as needed for shortness of breath or wheezing.
7. Percocet as needed for pain. Do not take tylenol while you
are taking this medication. This is a sedating medication; do
not take while operating a motor vehicle.
8. Reduced your Aspirin from 325mg to 81mg daily while you are
on coumadin.
9. Start Cefpodoxime for urinary tract infection, for 9 more
days (to end [**2141-4-10**]).
10. Start Lasix 20mg daily.
Call your cardiologist if you have questions or concerns with
your heart rate
Followup Instructions:
Follow up with:
Cardiology: Dr. [**Last Name (STitle) **] on [**2141-4-17**] at 3:00pm. Her telephone
number is [**Telephone/Fax (1) 36510**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]. The phone number is [**Telephone/Fax (1) 5294**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
Completed by:[**2141-4-3**]
ICD9 Codes: 5990, 4280, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4526
} | Medical Text: Admission Date: [**2124-3-4**] Discharge Date: [**2124-3-10**]
Date of Birth: [**2056-9-17**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13565**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 67 year old man man with history of seizure
disorder (since [**2088**]) who presented to [**Hospital6 10353**]
with a complex partial seizure with secondary generalization.
Prior to this episode he had been seizure free for 4 years on
Keppra, Dilantin, and Neurontin. He was in his usual state of
health until until Friday [**2123-3-4**] around 4:30 PM when his wife
found him sitting in his chair smacking his lips and staring
into the distance, a similar presentation to his typical
seizures (last seen well at 2:30 PM). His wife called the [**Name (NI) 14356**]
and his seizure had generalized with shaking when they arrived.
He was given Ativan 2 mg in the field with apparent resolution
of the seizure. He was transported to [**Hospital6 10353**]
where he reportedly had another seizure en route (per wife). On
arrival to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **], he was unresponsive with positive gag,
right lateral nystagmus, and slow respirations. He was thought
to be in status epilepticus, and was given another dose of
Ativan 2 mg followed by rapid sequence intubation for airway
protection. He was given a total of 14 mg IV Ativan and 400 mEq
IV phosphenytoin at [**Hospital1 392**]. He was febrile to 101.4 on arrival
and a CBC revealed leukocytosis to 18.5. An LP was done,
showing 1 WBC, glucose 98, and protein 63, and a urnialysis was
negative. A chest x-ray was done for ET tube placement, which
showed no acute cardiopulmonary process.
He was transferred to the [**Hospital1 18**] overnight on [**2124-3-4**] at 1AM due
to intubation. His wife does not know of any medication changes
and states he is compliant with his medications. His primary
neurologist is a Dr [**Last Name (STitle) 90003**] at JP VA. He arrived with a bag of
medications and it was noted that his Keppra bottle was expired
by a few years.
Past Medical History:
- Seizures: CPS with secondary generalization (since [**2088**])
- Hyperlipidemia
Social History:
He lives with wife and 23 year old son in [**Name (NI) 392**], MA. He is
retired from a company that works with Medicaid. He denies
tobacco, alcohol, and illicit drug use.
Family History:
No family history of seizures. Father died at 41 from "black
lung" (coal miner). Mother died at 62 from stroke.
Physical Exam:
On arrival (intubated):
Vitals: T:99.2 P: 90 R: 16 BP:115/68 SaO2:100% on Vent
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted,
Neck: In C-collar
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2,
Abdomen: soft, NT/ND.
Extremities: no edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intubated off sedation (propofol) but had
received Ativan/dilantin before arrival. Obtunded.
-Cranial Nerves: PEERL, Conjugate gaze. + gag with ETT.
-Motor: Moving all 4 ext.
-Sensory:+ grimace to pain in all 4 ext with withdraw. Plantar
response was flexor bilaterally.
Pertinent Results:
From [**Hospital3 **]:
Blood:
CBC:
18.4 > 16.3 / 49.0 < 245
N:74 L:16 M:6 E:1
CSF:
Tube 1: clear, colorless, 59 RBC, 1 WBC
Tube 4: clear, colorless, 0 RBC, 0 WBC, 98 glucose, 63 protein
On arrival:
[**2124-3-4**] 12:57AM LACTATE-1.7
[**2124-3-4**] 12:57AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-473*
PCO2-45 PH-7.39 TOTAL CO2-28 BASE XS-2 AADO2-209 REQ O2-43
-ASSIST/CON INTUBATED-INTUBATED
[**2124-3-4**] 01:30AM PT-12.8 PTT-20.4* INR(PT)-1.1
[**2124-3-4**] 01:30AM WBC-11.8* RBC-4.78 HGB-14.5 HCT-41.3 MCV-87
MCH-30.4 MCHC-35.1* RDW-13.3; NEUTS-87.7* LYMPHS-6.1* MONOS-5.7
EOS-0.1 BASOS-0.5
[**2124-3-4**] 01:30AM PHENYTOIN-9.9*
[**2124-3-4**] 01:30AM GLUCOSE-135* UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
[**2124-3-4**] 08:14PM PHENYTOIN-17.1
[**2124-3-4**] 09:12AM %HbA1c-5.8 eAG-120
[**2124-3-4**] 08:14PM GLUCOSE-101* UREA N-15 CREAT-1.1 SODIUM-134
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-27 ANION GAP-15
[**2124-3-4**] 08:14PM ALBUMIN-4.0 CALCIUM-8.3* PHOSPHATE-2.8
MAGNESIUM-2.0
Micro:
[**2124-3-7**] BLOOD CULTURE: PENDING
[**2124-3-7**] URINE CULTURE: PENDING
[**2124-3-4**] BLOOD CULTURE: PENDING
[**2124-3-4**] BLOOD CULTURE: PENDING
[**2124-3-4**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY (STREPTOCOCCUS PNEUMONIAE}
[**2124-3-4**] URINE CULTURE FINAL: No growth
[**2124-3-4**] MRSA SCREEN MRSA SCREEN-FINAL: Negative
[**2124-3-4**] URINE CULTURE-FINAL: No growth
[**2124-3-4**] BLOOD CULTURE: PENDING
[**2124-3-4**] BLOOD CULTURE: PENDING
Brief Hospital Course:
[**Known firstname 449**] [**Known lastname **] is a 67-year-old right-handed man with past medical
history notable for hyperlipidemia and epilepsy who is currently
admitted to the neurology inpatient
general service after sustaining a cluster of seizures as an
outpatient with subsequent intubation, a short stay in the neuro
ICU, and subsequent extubation.
# Neurologic: Mr. [**Known lastname **] had been doing very well with no
seizures for four years on the combination of Keppra and
Dilantin. He was initially brought to an OSH ED after being
found by his wife having a complex partial seizure that
secondarily generalized. He proceeded to have 2 additional
seizures en route to and at the OSH. He was given approximately
14 mg Ativan and loaded with Dilantin and subsequently intubated
prior to transfer to the [**Hospital1 18**]. He was extubated in the ICU and
ultimately transferred to the general neurology inpatient floor.
His Dilantin was increased slightly from 200/300 mg to 300 mg
[**Hospital1 **] and his Keppra was increased to 1000 mg [**Hospital1 **] after speaking
with his outpatient neurologist Dr. [**Last Name (STitle) 90004**]. There are no
obvious infectious metabolic or stress associated triggers that
we can elicit from him. He had an LP, which was normal and a
head CT which was unremarkable. From a seizure perspective, he
has been stable since his initial cluster of seizures that
initially brought him in. He was sent home on the higher doses
of Keppra and Dilantin as described above and is scheduled to
follow up with his outpatient neurologist, Dr. [**Last Name (STitle) 90004**] on [**3-20**], [**2123**].
# Infectious: An initial chest x-ray was concerning for
pneumonia. Given his fever and leukocytosis to 18.5 at the OSH
he was initially started on ceftriaxone and azithromycin which
was changed to Zosyn and Vancomycin due to the concern for
possible aspiration. His sputum revealed 4+ gram positive cocci
in sputum. A subsequent chest x-ray revealed that the prior
imaging showed artifact rather than consolidation. His fevers
and leukocytosis resolved and the rest of his infectious workup
including LP, urinalysis, and C. diff was negative, so his
antibiotics were discontinued. He remained symptom free from an
infection standpoint through his hospital course and was
afebrile for greater than 24 hours prior to discharge.
# Cardiovascular: He remained hemodynamically stable throught
his hospital course. He was continued on his home simvastatin 20
mg daily.
# Pulmonary: He arrived intubated from the outside hospital and
was extubated in the neuro ICU. There was initially concern for
possible aspiration pneumonia (above), but repeat chest x-ray
revealed no evidence of consolidation, so antibiotics were
discontinued as he was exhibiting no signs or symptoms of
infection.
# Endocrine: He was placed on an insulin sliding scale with a
goal blood sugar of 150, during his hospitalization and was
adequately controlled with blood sugars between 100 and 150.
Please fax d/c summary to outpatient neurologist Dr. [**Last Name (STitle) 90004**]
(fax: [**Telephone/Fax (1) 90005**])
Medications on Admission:
- Keppra 500mg [**Hospital1 **]
- Dilantin 200/300mg
- Neurontin 400mg TID
- Simvastatin 20 mg PO daily
- Vardenafil
- Calcium
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO BID (2 times a day).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
once a day.
7. vardenafil Oral
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GTC Seizure
S/P extubation. Intubated at OSH for airway protection.
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were initially admitted to [**Hospital3 **] for seizures. You
were intubated there and transferred to the [**Hospital1 18**], where you
taken to the intensive care unit. Your seizure medications were
changed while in the hospital (see below) after speaking with
Dr. [**Last Name (STitle) 90004**]. You remained seizure free while at the [**Hospital1 18**]. We
were initially concerned that you had pneumonia so you were
started on antibiotics. A later chest x-ray showed that you did
not have pneumonia and your fevers resolved, so we stopped the
antibiotics. It was a pleasure taking care of you.
Medication changes:
- Your Keppra was increased from 500 mg twice daily to 750 mg in
the morning and 1000 mg at night.
- Your Dilantin was increased from 200 in the morning and 300 at
night to 300 in the morning and 300 at night.
Followup Instructions:
Neurologist: Dr. [**Last Name (STitle) 90004**]: [**2124-3-20**]
Completed by:[**2124-3-10**]
ICD9 Codes: 5180, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4527
} | Medical Text: Admission Date: [**2174-8-11**] Discharge Date: [**2174-8-16**]
Date of Birth: [**2148-1-31**] Sex: F
Service: MED
Allergies:
Vancomycin / Ambisome
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Blood count with differential revealed leukocytosis with blasts,
indicating recurrence of her underlying disorder. According to
the family's request comfort-oriented care was made a priority.
On [**2174-8-16**], Ms. [**Known lastname 47828**] passed away secondary to underlying acute
myelogenous leukemia
Past Medical History:
AML dx [**3-9**] s/p 7+3 x 2 c/b typhlitis/appendicitis.
Pertinent Results:
[**2174-8-10**] 09:40AM WBC-17.7*# RBC-3.50* HGB-11.3* HCT-32.6*
MCV-93 MCH-32.2* MCHC-34.6 RDW-22.2*
[**2174-8-10**] 09:40AM NEUTS-55 BANDS-3 LYMPHS-7* MONOS-6 EOS-0
BASOS-0 ATYPS-6* METAS-1* MYELOS-1* BLASTS-21* NUC RBCS-4*
[**2174-8-11**] 08:30PM WBC-37.8*# RBC-3.33* HGB-10.8* HCT-32.2*
MCV-97 MCH-32.4* MCHC-33.5 RDW-23.4*
[**2174-8-11**] 08:30PM NEUTS-38* BANDS-2 LYMPHS-4* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-56* NUC RBCS-1*
Brief Hospital Course:
Blood count with differential revealed leukocytosis with blasts,
indicating recurrence of her underlying disorder. According to
the family's request comfort-oriented care was made a priority.
On [**2174-8-16**], Ms. [**Known lastname 47828**] passed away secondary to recurrent acute
myelogenous leukemia.
Discharge Disposition:
Home
Facility:
none
Discharge Diagnosis:
AML
Discharge Condition:
expired.
Discharge Instructions:
none.
Followup Instructions:
none.
ICD9 Codes: 2762, 2761, 486, 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4528
} | Medical Text: Admission Date: [**2120-1-15**] Discharge Date: [**2120-1-25**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Fever, AMS
Major Surgical or Invasive Procedure:
[**1-15**] right femoral line placement
[**1-15**] left tunneled catheter removal
[**1-16**] left arterial line placed
History of Present Illness:
61 male with history of seizure disorder, nonischemic
cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session on
saturday), hepatitis B, CAD, CVA, recent admission for line
bacteremia given vanco for 2 week course, who was at his rehab
center and found to be febrile with altered mental status and
hypoglycemia. His sugars there were in the 30s and he was given
oral glucose which improved his finger stick to 156. His
baseline mental status is A+0x3 but today he was A+O x2.
.
Pt had recent admission in [**11/2119**] for staph epidermidis and
CONS bacteremia, thought to be from tunnel line (tunnel tip grew
CONS). At that time, tunnel line was changed ([**2119-12-4**], fluro
guided tunnel line, exchanged over wire). Pt was given
vancomycin for 2 week course, dosed per HD protocol.
.
In the ED inital vitals were, T 102.2 HR 105 BP 94/44 RR 18 pOx
98% 2L. Tm 104.
Pt noted to have pus coming out of his tunnel line on left. His
temp spiked at 104, SBP initialy 160s. Tunnel line culture was
sent off.
AAOx2 (not to location).
Patient was given 4L NS, MAPs dropped to the low 60s, placed
femoral line (goal was to preserve other sites sinec pt likely
currently bactermic and will likely need new line), started
levophed infusion 0.06 (BP 94/45).
For fever of 104, given rectal tylenol 650mg, linezolid 600mg,
zosyn 4.5 (not given vanco bc history of VRE).
Cultures were obtained including blood, urine, HD catheter swab.
Labs were significant for CBC WBC 11.9, Hgb 9.4, HCT 31, PLT
366. N 88%. INR 1.3, PTT 34. Phos low at 1.6, Mg 2, Ca 9.7.
Lytes revealed UA: large euks, blood, 300+ protein, sh 1013, pH
6.5.
Na 135, K 5.1, Cl 94, Bicarb 25, BUN 33, Cr 8.2, Gluc 107. AG
was 16. Lactate 2.3.
ABG: pH 7.43, CO2 41, O2 58, HCO3 28
CXR showed: no signs of pneumonia, mildly increased pulm
vascular pressures.
Access includes 18G right and left forearm and right neck.
Femoral line and tunnel line.
Most Recent Vitals: 101 80/44 18 82 96% 2LNC
.
On arrival to the ICU, pt is A+O x3, states he has a doctorate
in history and music. He is at times sleepy, and at times very
sharp and able to answer questions such as the details of his
PhD. Denies any pain anywhere, no cough, no abd pain, last bm
yesterday, no diarrhea, states he has been admitted several
times for recurrent tunnel line infections.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- Seizure disorder since mid [**2097**]'s after starting dialysis
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- H/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 20-30%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
- Admission to MICU in [**10-2**] for seizure and hypotension
- Swab positive for MRSA and VRE at left groin site in [**10-2**] and
MRSA positive from same site [**11-2**]
- [**11/2119**] admission for staph epidermidis bacteremia and CONS
bacteremia sp vanco x 2 weeks
-[**9-/2119**]: MSSA and VRE bacteremia
-MSSA [**12/2117**] and [**4-/2118**]
Social History:
Retired piano and organ teacher. Has 2 PhDs (history and music)
and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at
baseline. Never smoker, no other drug use. Drinks 1 drink/week.
Has 2 sisters that live out of state, son died few years ago
("was shot to death").
Family History:
Father with DM, mother died at age 41 of renal failure
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: anterior lungs are clear bilaterally
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
left sternal border, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley with scant dark urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Slightly decreased skin turgor. Right knee with warm
patellar joint, ballotable.
Neuro: CN 2-12 intact, sensation throughout, [**4-27**] stregnth
throughout, small pinpoint pupils, EOM intact, A+O x3.
Pertinent Results:
LABS:
On admission:
[**2120-1-15**] 09:00AM BLOOD WBC-11.9*# RBC-3.63* Hgb-9.4* Hct-30.9*
MCV-85 MCH-25.8* MCHC-30.4* RDW-16.0* Plt Ct-366
[**2120-1-15**] 09:00AM BLOOD Neuts-88.0* Lymphs-6.1* Monos-3.1 Eos-2.7
Baso-0.1
[**2120-1-15**] 09:00AM BLOOD PT-14.0* PTT-34.0 INR(PT)-1.3*
[**2120-1-15**] 09:00AM BLOOD Glucose-107* UreaN-33* Creat-8.2*# Na-135
K-5.1 Cl-94* HCO3-25 AnGap-21*
[**2120-1-15**] 09:00AM BLOOD Calcium-9.7 Phos-1.6*# Mg-2.0
[**2120-1-15**] 02:59PM BLOOD TSH-0.45
[**2120-1-15**] 02:59PM BLOOD Cortsol-40.3*
[**2120-1-16**] 02:58AM BLOOD Cortsol-25.6*
[**2120-1-15**] 09:00AM BLOOD Digoxin-1.5
[**2120-1-15**] 09:11AM BLOOD pO2-58* pCO2-41 pH-7.43 calTCO2-28 Base
XS-2
[**2120-1-15**] 09:11AM BLOOD Glucose-102 Lactate-2.3* K-5.1 calHCO3-27
Micro:
Blood Cx [**1-16**], 25, 26, 29: no growth to date
Blood Cx [**1-15**]: MRSA
Femoral CVL tip [**1-19**]: no growth to date
HD catheter tip [**1-15**]: MRSA
Joint fluid: [**2120-1-17**] 12:00; culture showed no growth.
WBC RBC Polys Lymphs Monos
[**Telephone/Fax (1) 20491**] 81 17 2
[**1-15**] Wound swab (from prior HD cath site): MRSA
Urine cx: [**1-15**]: no growth
Studies:
[**2120-1-15**] Radiology CHEST (PORTABLE AP)
Mild cephalization which could reflect mild pulmonary venous
congestion.
[**2120-1-16**] Cardiovascular ECHO
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 55%) with
subtle basal inferior hypokinesis. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2119-11-30**], the LVEF has improved.
[**2120-1-17**] Radiology KNEE 2 VIEW PORTABLE RI
There are degenerative changes with narrowing of the lateral
compartment which causes valgus angulation at the knee. There is
spurring at the inferior pole of the patella. There is no joint
effusion. There are no focal lytic or blastic lesions. There is
some soft tissue swelling.
[**2120-1-18**] Radiology CHEST (PORTABLE AP)
HD catheter has been removed. There is no evident pneumothorax.
If any there is a small right pleural effusion. Cardiac size is
top normal. The aorta is tortuous. The chin of the patient
obscures the right apex. There is mild vascular congestion.
There are no new abnormalities from [**1-15**]. There are low
lung volumes. Widened mediastinum and deviation of the trachea
towards the right is due to enlarged thyroid gland. Multiple
left rib fractures are noted.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
This is 61 male with history of seizure disorder, nonischemic
cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session
saturday), hepatitis B, CAD, CVA, several admissions in the past
for tunnel associated MSSA/CONS/VRE bacteremia, recent admission
1 month ago for Staph epidermidis and CONS line bacteremia given
vanco for 2 week course, who presented with MRSA bacteremia
likely due to an infected tunnel line.
.
ACTIVE ISSUES
SEPTIC SHOCK: The patient persented with Fever (Tm 104),
Leukocytosis (WBC 12), Tachycardia (HR 100s), lactate 2.3,
mental status change, and BP 94/44 on low dose Levophed and
after 4L, consistent with septic shock. Methicillin resistant
staph aureus grew from the [**3-27**] blood culture bottles, swab of
the catheter and culture of the tip of the catheter line. Pus
was noted surrounding the catheter site which was evaluated by
general surgery and no I/D indicated. His urine culture
revealed no growth despite large amount of leukocytes. His
presenting chest xray was clear and joint fluid analysis of his
right knee was not consistent with septic arthritis. A TTE
demonstrated no evidence of vegetations. A TEE was deferred
given it would not change antibiotic duration. He briefly
required pressor support with levophed via a femoral line placed
in the ED. He was initially started on linezolid which was
discontinued in favor of vancomycin and zosyn in the intensive
care unit which were narrowed to vancomycin alone when culture
data was available. His HD was line was removed and he HD was
deferred for 1 week before a temporary femoral line was placed.
Surveillance blood cultures were all negative following his
admission cultures on [**2120-1-15**]. Duration of therapy 6 weeks
([**0-0-**]) with vancomycin to be given with HD. A
tunneled right subclavian line was placed prior to discharge.
.
ESRD: T/Th/Sat. Last HD prior to admission was 2 days PTA, on
Saturday. HD was deferred for as long as possible, to allow for
a line holiday given segnificant bacteremia and sepsis. Patient
was monitored on telemetry, electrolytes checked daily, small
boluses of fluid given for hypotension. HD cath pulled [**1-15**].
line was replaced on [**1-19**], w/ HD on [**1-20**], now back on prior
Tu/Th/Sat schedule.
.
ALTERED MENTAL STATUS: Patient is significantly altered from
baseline. Initially, AMS felt to be due to hypoglycemia. Likely
multifactorial-- septic shock, uremia. Per patient??????s family,
his mental status has been declining for >1 year. Neuro exam non
focal. Patient had one witnessed seizure on the day of HD (5
days into admission), and it was discovered that he had been
under dosed on his keppra during the admission. It is possible
that he has been having seizures during this time that have been
affecting his MS, however, his postictal state is not similar to
his mental status throughout the admission. Mental status
continued to improved. RPR negative. B12 and folate wnl. TSH
wnl. Head CT in [**2119-8-24**] demonstrated expected expected
age-related changes. [**Month (only) 116**] consider neurocognitive testing in the
outpatient setting.
.
HYPOGLYCEMIA: Likely [**1-25**] acute infectious state. Can also see in
renal failure (because insulin cleared by kidneys), hypopit (pt
has known pituitary mass), adrenal insuf (had normal cortisol Am
level check on prior admission), insulinoma. Most likely
etiology is sepsis. TSH WNL. Patient's blood glucose WNL after 1
day into admission.
.
SEIZURE DISORDER: Patient is on oxcarbazepine and keppra as an
outpatient. Patient was underdosed Keppra during his HD vacation
this admission. He experienced a brief localized seizure
consisting of 1 minute of facial twitching 5 days into
admission. Pt was apparently on the incorrect seizure
medication, which was per his prior d/c summary and outside
facility list (was ~ [**12-26**] of his appropriate dose [**First Name8 (NamePattern2) **] [**2119-5-24**]
neuro note). Pt??????s prior seizures were more generalized, last
documented in [**2117**], attributed to medication non-compliance.
Neurology was consulted and Pt was restarted on Keppra 500 tid
plus 500 mg dose after HD, and oxcarbazepine 300 mg tid plus 300
mg dose after HD. Pt apparently tends to have seizures after HD.
Pt states that he typically has a small facial seizure every few
months. Pt did not have any further seizures during his
hospitalization.
.
ANION GAP METABOLIC ACID: Likely [**1-25**] lactic acidosis and renal
failure. Gap closed as patient restarted on HD 5 days into
admission.
.
CAD/CHF: Mild pulm edema on CXR, however on exam pt appears
mildly volume down with some decreased skin turgor. Pt given
several liters of IVF in setting of septic shock. He is at risk
for pulmonary edema so will trend his O2 requirement and exam
closely. HD was restarted 5 days into admission, which will
manage volume status. Continued home simvastatin and ASA, and
digoxin dosed according to HD.
.
ANEMIA: HCT baseline 27-30. HCT currently 31, at baseline.
Likely multifactorial: anemia [**1-25**] ESRD and anemia of chronic
disease. He was given epoeitin in dialysis.
.
INR 1.3: Likely [**1-25**] poor nutrition, recent antibiotics. No
diarrhea. INR trended. He was given vitamin K prior to discharge
.
HYPOPHOSPHOTEMIA: Phos 1.9 on admission (repleted), lower then
expected given renal failure. Pt is sp parathyroidectomy.
Differential includes poor nutrition, osetomalacia, diuretics,
hyper-parathyropidism, hyperthyroidism, recovery from
starvation, steroids. Baseline phos is usualy [**1-27**]. Repeat Phos
levels remained WNL. TSH WNL, PTH high.
.
RIGHT KNEE PAIN. Pt was complaining about knee effusion, which
felt warm and was tapped by orthopedic service. Fluid showed 200
WBC, 1625 RBC, 81% Polys 17% Lymphs, no organisms on gram stain,
no crystals. Pt was treated with analgesics with improvement in
his pain.
.
TRANSITIONAL ISSUES
- vancomycin for 6 weeks (last date [**2120-2-27**])
- consider neurocognitive testing
Medications on Admission:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA): extra dose to be given on dialysis days after
dialysis.
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three
times a week (Tues, Thurs, Sat): extra dose to be given on
dialysis days after dialysis.
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: do not exceed 4 grams in 24
hours.
14. aspirin 81 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. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
17. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime:
hold for loose stools; pt may refuse.
18. chlorhexidine gluconate 4 % Liquid Sig: One (1) Topical [**12-25**]
times each week.
19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once
a day: APPLY LIBERALLY TO SKIN ON HANDS, FEET
20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed
Intravenous HD PROTOCOL (HD Protochol): To be dosed based on
trough and given on hemodialysis; continue until [**2119-12-13**].
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day.
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS
().
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY
().
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily).
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous with HD for 1 doses: To be dosed based on trough and
given on hemodialysis days. (Duration 6 weeks, last day
[**2120-2-28**]).
Disp:*qS * Refills:*0*
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
1. Methicillin Resistant Staphylococcus Aureus Bactermia
2. End Stage Renal Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 2026**],
.
You were admitted for a fever and found to have another
infection in your blood likely related to your hemodialysis
line. Your tunneled catheter was removed and dialysis was
stopped for 1 week. A temporary catheter was then placed in your
groin before a new tunneled catheter could be placed in your
right subclavian site. You will need to continue antibiotics
for a total of 6 weeks.
.
The following changes were made to your medication list:
1. CONTINUE Vancomycin with hemodialysis for 6 weeks (last day
[**2120-2-27**])
2. STOP Ferrous Sulfate
3. HOLD Sevelamer until otherwise directed
4. HOLD Calcium acetate until otherwise directed
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the physicians at your facility and your
outpatient nephrologists.
ICD9 Codes: 5856, 4254, 2762, 412, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4529
} | Medical Text: Admission Date: [**2135-12-21**] Discharge Date: [**2136-1-3**]
Date of Birth: [**2081-4-3**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient was transferred to
[**Hospital1 **] on [**2135-12-21**] and underwent exploratory
laparotomy and drainage of a pelvic abscess and loop
sigmoidoscopy.
The patient is a 54 year-old male with a history of
pancreatitis and cardiomyopathy from ETOH abuse with an
ejection fraction of 15% and coronary artery bypass graft in
[**2134-9-24**] and a history of coronary artery disease,
diabetes, chronic renal insufficiency, history of hepatic
abscess and cerebrovascular accident times two, pancytopenia,
chronic obstructive pulmonary disease, CRI, glaucoma. The
patient was admitted urgently on [**12-20**] to [**Hospital 2725**]
Hospital for abdominal pain and guarding for four days. He
had left lower quadrant pain, chills and rigors. CT scan
showed an ischemic bowel and liver abscess and edematous
bowel. The patient was transferred to the [**Hospital1 346**] on [**2135-12-21**].
HOSPITAL COURSE: On [**2135-12-21**] the patient was taken
by Dr. [**Last Name (STitle) 1305**] to the Operating Room and underwent an
exploratory laparotomy and a pelvic abscess was discovered
and that was subsequently drained and the cause of the
patient's acute abdomen was believed to be a perforated
diverticulitis, so a loop of sigmoid colon was brought out
through an ostomy a mature sigmoid colon and the intent was
to see if we could identify a leak meanwhile.
Postoperatively, the patient was transferred to the Intensive
Care Unit and was stable in the Intensive Care Unit and was
placed on antibiotics. The culture from the abscess grew out
E-coli that was pan sensitive and antibiotics were adjusted
accordingly. The patient's Intensive Care Unit stay was
uneventful. On [**12-24**] the patient was started on TPN and
on [**12-27**] the patient was transferred to the floor and
interventional radiology performed CT guided drainage of a
hepatic abscess on [**12-28**] and on [**12-29**] the patient
was stable on the floor and was afebrile with stable vital
signs and was deemed that the patient did not require a
sigmoidostomy and the patient was taken to the Operating Room
and underwent reversal of a matured loop sigmoidostomy on
[**2135-12-29**].
Postoperatively, the patient did well and recovery was
uneventful. Two days after reversal of the sigmoidostomy the
nasogastric tube was discontinued and the patient was put on
clear liquids. The patient had bowel movements and was
passing gas and tolerating regular po.
Physical examination prior to discharge, the patient was
afebrile. Vital signs were stable. Incision was clean, dry
and intact. Belly was nondistended. Nontender. The pigtail
drain for the hepatic abscess was in place. Prior to
discharge the patient had a CT scan to reassess the hepatic
abscess. Shows hepatic abscess has significantly decreased
in size. The culture from the pigtail drain was negative.
No organism was grown. The patient will be discharged on
[**2136-1-3**] to a rehab facility.
DISCHARGE MEDICATIONS: Levaquin 500 mg po q.d. times ten
days, Flagyl 500 mg po q 6 h. times ten days, Lopressor 50 mg
po b.i.d., Oxacillin 1 gram po q 6 h times ten days, Lasix 20
mg po b.i.d.
The patient will be discharged with a pigtail drain in the
right upper quadrant and the patient is told to follow up
with Dr. [**Last Name (STitle) 1305**] in one week for reassessment of the hepatic
abscess and the wound check.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2136-1-3**] 08:15
T: [**2136-1-3**] 08:25
JOB#: [**Job Number 37265**]
ICD9 Codes: 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4530
} | Medical Text: Admission Date: [**2107-5-24**] Discharge Date: [**2107-5-29**]
Date of Birth: [**2050-4-20**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Avandia / Cefoxitin / Humalog / Lantus / Glucophage / Ibuprofen
/ Neurontin / Tylenol / Glucovance / Glyburide / Levaquin /
Keflex / Topamax / Aspirin / Cymbalta / Metformin / Shellfish
Derived
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Right hip pain / Osteoarthritis
Major Surgical or Invasive Procedure:
[**2107-5-24**] Right total hip replacement
History of Present Illness:
57M with B/L hip OA, s/p L THA in '[**05**] now presents for right
THA.
Past Medical History:
htn,OSA,CHF,dyslipid,ischemic heart disease,s/p
MI,PVD,DM,reflux,renal insuffic,anemia of chronic disease
Social History:
smoker,currently [**12-25**] PPD but formerly as much as 4 PPD. quit
etoh in [**2091**]. Lives alone.
Employment:used to work for Stop and Shop
Family History:
nc
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with baseline neuropathy RLE.
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength TA/GS/[**Last Name (un) 938**]/FHL
* [**Last Name (un) **]: neuropathy RLE as per baseline.
* Toes warm
Pertinent Results:
[**2107-5-28**] 05:40AM BLOOD WBC-10.0 RBC-2.96* Hgb-9.9* Hct-30.1*
MCV-102* MCH-33.5* MCHC-32.9 RDW-13.3 Plt Ct-193
[**2107-5-27**] 05:23AM BLOOD WBC-12.0* RBC-2.94* Hgb-10.1* Hct-30.0*
MCV-102* MCH-34.4* MCHC-33.7 RDW-13.6 Plt Ct-164
[**2107-5-26**] 03:35AM BLOOD WBC-13.1* RBC-3.29* Hgb-11.4* Hct-33.1*
MCV-101* MCH-34.6* MCHC-34.4 RDW-13.8 Plt Ct-171
[**2107-5-25**] 11:04PM BLOOD Hct-32.2*
[**2107-5-25**] 12:15PM BLOOD WBC-14.2* RBC-3.47* Hgb-11.4* Hct-34.6*
MCV-100* MCH-32.8* MCHC-32.8 RDW-13.4 Plt Ct-180
[**2107-5-25**] 04:09AM BLOOD WBC-15.1* RBC-3.92* Hgb-13.2*# Hct-39.6*
MCV-101* MCH-33.6* MCHC-33.3 RDW-13.7 Plt Ct-238
[**2107-5-25**] 02:14AM BLOOD Hct-37.9*#
[**2107-5-24**] 07:25PM BLOOD WBC-17.5* RBC-4.99 Hgb-16.3 Hct-50.3
MCV-101* MCH-32.7* MCHC-32.5 RDW-13.4 Plt Ct-183
[**2107-5-29**] 08:30AM BLOOD PT-15.6* INR(PT)-1.4*
[**2107-5-28**] 05:40AM BLOOD Plt Ct-193
[**2107-5-28**] 05:40AM BLOOD PT-12.8 INR(PT)-1.1
[**2107-5-28**] 05:40AM BLOOD Glucose-227* UreaN-18 Creat-1.5* Na-135
K-4.6 Cl-99 HCO3-27 AnGap-14
[**2107-5-27**] 05:23AM BLOOD Glucose-179* UreaN-16 Creat-1.4* Na-133
K-4.6 Cl-101 HCO3-26 AnGap-11
[**2107-5-25**] 11:04PM BLOOD Glucose-312* UreaN-22* Creat-1.7* Na-133
K-4.6 Cl-101 HCO3-21* AnGap-16
[**2107-5-25**] 12:15PM BLOOD Glucose-349* UreaN-23* Creat-2.0* Na-129*
K-5.2* Cl-100 HCO3-21* AnGap-13
[**2107-5-25**] 04:09AM BLOOD Glucose-288* UreaN-26* Creat-2.1* Na-134
K-6.2* Cl-103 HCO3-21* AnGap-16
[**2107-5-24**] 07:25PM BLOOD Glucose-201* UreaN-22* Creat-1.9* Na-137
K-5.2* Cl-105 HCO3-24 AnGap-13
[**2107-5-28**] 05:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7
[**2107-5-27**] 05:23AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
[**2107-5-26**] 03:35AM BLOOD calTIBC-241* VitB12-355 Folate-GREATER TH
Ferritn-250 TRF-185*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received heparin GTT to PTT>60 then lovenox 120mg [**Hospital1 **] for DVT
prophylaxis starting on POD 0 until INR >2. medicine service
was consulted and aided in overall management. They do
recommend PCP to do [**Name Initial (PRE) **] OSA w/u after discharge as an outpatient.
The foley was removed on POD#2 and the patient was voiding
independently thereafter. The surgical dressing was changed on
POD#2 and the surgical incision was found to be clean and intact
without erythema or abnormal drainage. The patient was seen
daily by physical therapy. Labs were checked throughout the
hospital course and repleted accordingly. No blood transfusion
was required. At the time of discharge the patient was
tolerating a regular diabetic diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. His BS were followed by the Diabetic team,
[**Last Name (un) **], while inhouse and improved throughout his stay though
they will need to be followed at rehab closely. The operative
extremity was neurovascularly stable and the wound was benign.
At time of discharge, patient was deemed stable for safe
discharge to rehab.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior hip
precautions.
Medications on Admission:
Allopurinol, atenolol, buproprion, cilostazol, plavix, dilaudid,
novolog, levemir, omperazole, lyrica, simvastatin, ASA
Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
19. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
20. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
23. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Q MONDAY TO
THURSDAY (): Check daily INR. When INR >2, DC lovenox and dose
coumadin to INR [**1-26**]. .
24. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Check daily INR. When INR >2, DC lovenox
and dose coumadin to INR [**1-26**]. .
25. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
26. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
27. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB,
wheezing.
28. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for Pain: Do not drive, operate machinery or
instruments while taking this medication.
Disp:*80 Tablet(s)* Refills:*0*
29. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Q FRIDAY,
SATURDAY AND SUNDAY (): Take 4mg po MON-TH
Take 7mg po FRI-SUN
Your INR will be checked while in rehab and you will need labs
drawn once an outpt with f/u of your INR levels by your PCP.
[**Name10 (NameIs) **] daily INR. .
Disp:*100 Tablet(s)* Refills:*1*
30. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
4mg po MON-TH
Take 7mg po FRI-SUN
Your INR will be checked while in rehab and you will need labs
drawn once an outpt with f/u of your INR levels by your PCP.
[**Name10 (NameIs) **] daily INR. .
Disp:*100 Tablet(s)* Refills:*1*
31. Insulin Detemir 100 unit/mL Solution Sig: Eighty (80) U
Subcutaneous twice a day: Breakfast/bedtime.
32. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale
Subcutaneous every six (6) hours: SScale inhouse:
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
.
33. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
34. Promethazine 25 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Right hip osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Your INR will be checked while in rehab and
you will need labs drawn once an outpt with f/u of your INR
levels by your PCP. [**Name10 (NameIs) **] daily INR. When INR >2, DC lovenox
and dose coumadin to INR [**1-26**]. You will then continue coumadin
as an outpt with your PCP checking the INR level and dosing it.
If you have any questions, please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) **].
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Posterior hip precautions. No strenuous exercise or
heavy lifting until follow up appointment.
Physical Therapy:
WBAT RLE. Posterior hip precautions.
Treatments Frequency:
1. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
2. Your INR will be checked while in rehab and you will need
labs drawn once an outpt with f/u of your INR levels by your
PCP. [**Name10 (NameIs) **] daily INR. When INR >2, DC lovenox and dose coumadin
to INR [**1-26**].
Followup Instructions:
You will need to follow-up with pulmonary and will likely will
need to have sleep study.
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2107-6-24**] 11:20
Completed by:[**2107-5-29**]
ICD9 Codes: 5849, 5180, 2762, 2724, 5859, 4280, 3051, 4439, 412, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4531
} | Medical Text: Admission Date: [**2156-9-20**] Discharge Date: [**2156-10-2**]
Service: MEDICINE
Allergies:
Tape
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
tracheostomy placement
PEG tube placement
Intubated and Ventilated
History of Present Illness:
89 y/o M h/o end stage parkinson's, dysphagia, GERD presented to
ED after episode of choking in the afternoon. Of note he has had
recent FTT and there was discussion with Dr. [**Last Name (STitle) 665**], his PCP of
placing [**Name Initial (PRE) **] PEG tube. He had recently done better tolerating meals
over the past few months, past few days he has had episodes of
choking with meals with likely aspiration. Daughter gave him a
few nebulizer treatments and his respiratory distress did not
improve so she called EMS.
.
In the ED, respiratory difficulty throughout day, daughter gave
nebs, EMS tachypneic, 90% room air, 40s RR, tired out, lots of
secretions, mental status diminished, intubated in that setting
for airway protection. Right IJ in place, lactate 4.1, CXR with
infiltrates. U/A clean. ECG unchanged. 2 liters fluid given, HR
decreased from 130s to 80s after fluids. CVP not transduced,
apparently good UOP.
Received levofloxacin 750mg, metronidazole 500mg, ceftriaxone
1g, vancomycin 1 g
Vitals upon leaving ER: 100.3 rectally, 81, 95/55, 100% on 100%
FiO2 AC
Past Medical History:
1. Parkinson's disease diagnosed in [**2146**].
2. Macular degeneration.
3. Gastroesophageal reflux.
4. Coccygeal skin breakdown.
5. BPH.
6. Cataract.
7. Carpal tunnel.
8. Cervical stenosis.
9. Gait instability with a history of falls. He has a history of
right leg buckling under him, and he wears a knee brace for this
purpose. He is being followed by Physical Therapy at home
10. Zoster [**2154**]
Social History:
Lives in [**Location 1268**] with daughter. Chinese immigrant, retired
pharmacist. Used to smoke cigarettes, but last smoked in the
70s; no alcohol. He is widowed and has 5 children. He walks with
a walker or uses a wheelchair. He lives at home and is attended
to by his daughter (a dentist) during the evening and overnight;
and he has a home health aid who sees him during the day while
his daughter is at work.
Family History:
Noncontributory.
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2156-9-20**] 08:02PM WBC-10.2 RBC-3.43* HGB-11.7* HCT-35.3*
MCV-103* MCH-34.0* MCHC-33.1 RDW-12.3
[**2156-9-20**] 08:02PM NEUTS-88.7* LYMPHS-8.4* MONOS-2.6 EOS-0.2
BASOS-0.1
[**2156-9-20**] 08:02PM cTropnT-<0.01
[**2156-9-20**] 08:02PM ALT(SGPT)-25 AST(SGOT)-27 LD(LDH)-232
CK(CPK)-54 ALK PHOS-69 AMYLASE-102* TOT BILI-0.4
[**2156-9-20**] 08:13PM LACTATE-4.1*
[**2156-9-20**] 09:16PM HGB-10.6* calcHCT-32 O2 SAT-97
FRONTAL CHEST RADIOGRAPH [**9-27**]
INDICATION: 89-year-old man with ARDS, ventilated.
COMPARISON: Multiple prior studies, most recent dated [**2156-9-26**].
FINDINGS: Support devices remain in standard positions.
Multifocal patchy
opacities remain present, have increased in extent particularly
in
perihilar regions, concernign for volume overload. Bilateral
pleural effusions
are stable.
IMPRESSION: Worsening of multifocal bilateral opacities, given
perihilar
predominance concerning for volume overload.
FRONTAL CHEST RADIOGRAPH [**9-29**]
INDICATION: 89-year-old man with ARDS.
COMPARISON: Multiple prior studies, most recent dated [**2156-9-28**], 5:45
a.m.
FINDINGS: The support devices are in unchanged standard
positions. Overall,
the appearance of the chest is unchanged from the prior study,
including
bilateral extensive multifocal opacities as well as small
pleural effusions.
IMPRESSION: No interval change from [**2156-9-28**].
Lower Extremity US [**9-27**]
FINDINGS: Ultrasound evaluation of the right and left lower
extremities deep
venous system reveals the veins to be fully compressible with
normal color
flow, Doppler waveforms, augmentation, and respiratory variation
in flow.
IMPRESSION: No evidence of DVT involving the right or left lower
extremity.
Head CT [**10-1**]
Impression: No evidence for hemorrhage or acute infarction.
Brief Hospital Course:
# Patient was admitted with septic shock secondary to
aspiration, as patient has end stage Parkinson's disease and
history of difficult swallowing. Initial chest x-ray showed
bilateral opacities. Subsequent chest x-rays showed bilateral
opacities consistent with ARDS, with no significant change over
the course of his hospital stay. Patient was continued on
empiric antibiotics Vancomycin and Cefepime for aspiration
pneumonia, for 8 day course. Sputum cultures grew MRSA,
Klebsiella and rare gram negative rods.
# Respiratory failure secondary to aspiration. Patient was
intubated on admission, and remained ventilator dependent
despite efforts to extubate him. He received a tracheostomy
after 9 days of intubation and failure to extubate.
# Hypotension: Attributed to sepsis. Lowest systolic blood
pressure was in the 70s. On admission patient required Levophed
to maintain blood pressure. This was gradually weaned off prior
to discharge. Baseline systolic blood pressures 80s-90s.
# Nutrition: Patient was started on tube feeds during hospital
stay. A PEG tube was placed prior to discharge.
# Sacral Decubitus Ulcer: This began months prior to admission.
Patient was evaluated by Wound care nurse. Patient was kept on
an air mattress, and repositioned q 1-2 hours to keep pressure
off coccyx. Heels were kept off of the bed surface. Lower
extremities were moisturized twice daily.
# Atrial tachycardia: Patient developed tachycardia, likely
atrial flutter once during admission that resolved with
diltiazem rate control. He was started on Digoxin with dig
level of 1.2 day prior to discharge. Cardiac enzymes were
negative x3.
Medications on Admission:
OUTPATIENT MEDICATIONS:
Adefovir 10 mg daily
Albuterol 2 puffs up to QID prn
Alprazolam 1 mg q6 hours prn anxiety
Dicyclomine 10 mg TID
Fluticasone 50 mcg [**2-11**] sprays in nostrils prn
Advair Diskus 500-50, one inhalation [**Hospital1 **]
HCTZ 25 mg daily
Mirtazapine 15 mg qhs
Omeprazole 20 mg daily
Oxazepam 15 po qhs prn
Zoloft 150 mg daily
Tiotropium bromide 18 mcg capsule INH daily
Trazadone 50 mg daily (?)
Oxygen 1 L/min at rest and 2 L/min during sleep and exertion,
for resting Sat of 88% on r.a which drops to 78% with exertion.
Keeping his Sat> or = to 90%
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous
membrane [**Hospital1 **] (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Neomycin-Bacitracin-Polymyxin Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day) as needed.
9. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
14. Morphine 10 mg/mL Solution Sig: One (1) Intravenous Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
1. Respiratory failure secondary to ARDS
2. Aspiration pneumonia
3. Baseline relative hypotension (systolic blood pressures in
80s-90s)
4. Baseline poor neurologic function
5. Sacral decubitus ulcer
6. Paroxysmal atrial tachycardial: afib vs. MAT
Secondary diagnoses:
1. Parkinson's disease diagnosed in [**2146**].
2. Macular degeneration.
3. Gastroesophageal reflux.
4. Coccygeal skin breakdown.
5. BPH.
6. Cataract.
7. Carpal tunnel.
8. Cervical stenosis.
9. Gait instability with a history of falls. He has a history of
right leg buckling under him, and he wears a knee brace for this
purpose. He is being followed by Physical Therapy at home
10. Zoster [**2154**]
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the Intensive Care Unit with sepsis due to
aspiration pneumonia. You were put on a ventilator as you
weren't able to breathe for yourself. After 9 days on the
ventilator, you had a tracheostomy (a tube put in your throat)
and a PEG tube placed in your stomach for feeding. You were
treated with antibiotics for pneumonia. Your decubitus ulcers
were treated with wound care.
Please return to the ER, if you are unable to breathe, are
unable to maintain systolic blood pressure above 75, or have
recurrent fevers, low blood pressure, and increased heart rate
over 100.
Followup Instructions:
PCP: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 665**] [**2156-10-13**] at Noon
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2156-10-2**]
ICD9 Codes: 0389, 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4532
} | Medical Text: Admission Date: [**2123-10-15**] Discharge Date: [**2123-10-17**]
Date of Birth: [**2067-11-14**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old female
with a past medical history of diabetes, hypertension,
chronic renal insufficiency, who presented with nausea,
vomiting, dehydration, and hyperglycemia/DKA, as well as
headaches and dizziness x3 weeks. In the ED, the patient was
found to be hypertensive to the 220 systolic.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insulin dependent diabetes.
3. Atypical chest pain.
4. Chronic renal insufficiency, baseline 1.2-1.5.
5. Asthma.
6. Depression.
7. B12 deficiency.
8. History of UTIs.
9. History of small bowel obstructions x2.
10. Spinal stenosis with a left foot neuropathy.
11. Status post gastric bypass surgery in [**2113**].
12. Status post cholecystectomy.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco and no alcohol. Lives with
daughter and granddaughter.
FAMILY HISTORY: Mother with hypertension and migraines.
Father with hypertension and CAD.
OUTPATIENT MEDICATIONS:
1. Lipitor 10 mg a day.
2. Atenolol 50 mg a day.
3. Cozaar 25 mg a day.
4. B12 100 mcg a day.
5. Insulin NPH 25 units q.a.m. and 16 units q bedtime.
6. Regular insulin-sliding scale.
PHYSICAL EXAM ON ADMISSION: Temperature 96.8, blood pressure
186/74, heart rate 93, respiratory rate 15, and 97% on room
air. General: Pleasant female in no acute distress. Heart
was regular, rate, and rhythm S1, S2. Lungs were clear to
auscultation bilaterally. Abdomen was obese, soft,
nontender, and positive bowel sounds. Extremities: No
clubbing, cyanosis, or edema. Neurologic: Awake, alert, and
oriented times three. Mentating well. Cranial nerves II
through XII are intact. Reflexes are 2+ and symmetric
bilaterally. Negative Kernig's and negative Brudzinski's.
Strength is [**4-5**] in all extremities. Sensation is intact.
LABORATORY DATA ON ADMISSION: White count 10.5, hematocrit
47.2, platelets 312. Sodium 138, potassium 5.9, chloride
102, bicarb 22, BUN 34, creatinine 2.0, glucose 309. Calcium
9.3, magnesium 18, phosphorus 5.3. Albumin 4.4, total
bilirubin 0.4, ALT 18, AST 74, alkaline phosphatase 298,
lipase 74, INR 1.1. CK 173 down to 130, MB of 5 and troponin
negative x2. ABG: 7.34/41/89, lactate 2.7.
CT head: No hemorrhage, no mass effect, and normal head CT.
Chest x-ray: No acute process.
KUB: Stool throughout colon, no dilated loops of bowel.
EKG: Normal axis or intervals, slight ST depression
laterally, slight tachycardia at 95.
Urinalysis: Moderate blood, 500 protein, 1,000 glucose,
negative for ketones, negative leuks, no reds, no whites,
occasional bacteria, and no yeast.
HOSPITAL COURSE BY PROBLEM:
1. Diabetic ketoacidosis: Patient with an anion gap of 17,
but negative ketones in the serum and urine. There was no
clear precipitating factor. Urine cultures and blood
cultures were negative. Patient was treated with an insulin
drip and IV fluids with better control of her sugars and by
the following morning had no further nausea, vomiting, and
felt much improved. Patient was changed over to regular
insulin-sliding scale and will be discharged on her home dose
of NPH.
2. Headache: Patient underwent a CT of the head as well as
MRI which were both negative for pathology. Originally,
there was a concern for possible subarachnoid hemorrhage,
therefore a lumbar puncture was attempted, however, it
failed. Neurology was consulted, and felt that as
patient's symptoms improved after IV fluids and control of
her hyperglycemia, there was no need for further workup
unless the headache intensity increased again.
3. Cardiovascular: Patient had diffuse ST depressions on
admission EKG. Repeat EKG showed that these depressions had
resolved. Patient was ruled out for MI. Troponin was
negative x3. Patient was continued on aspirin and beta
blocker. It was felt that the patient may benefit from an
outpatient ETT MIBI in the future.
4. Chronic renal insufficiency: Patient's creatinine was
near baseline at the time of discharge.
5. Increased CKs/increased AST: Patient with elevated CKs to
the 250s as well as a high AST during this admission. This
was felt to be possibly secondary to Lipitor as this was a
new medication for the patient, and therefore Lipitor was
held. Patient was asked to followup with her primary
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] regarding this issue.
6. Hypertension: Patient was continued on her losartan and
her atenolol was increased to 75 mg q.d.
7. Abdominal pain: This was felt to be chronic in nature and
thought to be possibly secondary to adhesions. Patient has
had a history of multiple abdominal surgeries including two
small bowel obstructions. Patient had a CT of the abdomen
that was negative for pathology.
8. Status post gastric bypass: CT of the abdomen did show a
communication between the excluded and the neostomach. It
was felt that contrast had filled the excluded stomach and it
had not filled as reflux from the distal limb, therefore,
there must be an abnormal communication. Patient will likely
need followup regarding this matter as well.
At discharge, patient was in good condition with adequately
controlled blood sugars and hypertension, and with much
improved symptoms.
FINAL DIAGNOSIS: Diabetic ketoacidosis.
SECONDARY DIAGNOSES:
1. Anemia.
2. Hypertension.
RECOMMENDED FOLLOWUP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1-2 weeks as
well as to have an outpatient stress test and for followup
regarding her gastric bypass surgery.
DISCHARGE MEDICATIONS:
1. Losartan 25 mg once a day.
2. Aspirin 81 mg a day.
3. Atenolol 75 mg a day.
4. Vitamin B12 50 mcg a day.
5. NPH insulin 24 units q.a.m., 16 units q.p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2123-10-17**] 16:37
T: [**2123-10-19**] 06:45
JOB#: [**Job Number 22443**]
ICD9 Codes: 2765, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4533
} | Medical Text: Admission Date: [**2159-9-26**] Discharge Date: [**2159-10-3**]
Date of Birth: [**2086-6-5**] Sex: M
Service: C-MED
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with a long history of coronary artery disease
(including multiple coronary artery bypass grafts in [**2128**], in
[**2132**], and in [**2159-8-16**]; and several percutaneous
transluminal coronary angioplasties) who was transferred to
the C-MED Service from the Coronary Care Unit.
The patient was initially admitted to the [**Hospital3 2358**] on
[**2159-9-25**] for an episode of substernal chest
discomfort while driving his car to a family event. In
addition to the chest discomfort, the patient also had the
abrupt onset of shortness of breath and nausea. All of his
symptoms, except the shortness of breath, were relieved with
sublingual nitroglycerin.
The patient states he had been doing well since his prior CT
surgery back in [**2159-8-16**]; denying any chest pain since
discharge. He has not noticed any significant decrease in
his exercise tolerance; however, he does admit to some mild
lower extremity swelling and some shortness of breath at
night while lying flat.
An echocardiogram performed at the [**Hospital3 2358**] was
significant for a dilated left ventricle with severe left
ventricular dysfunction with an ejection fraction of 15% to
20%, 4+ mitral insufficiency, and trace aortic insufficiency.
He was subsequently transferred to the [**Hospital1 190**] for cardiac catheterization.
A diagnostic cardiac catheterization at [**Hospital1 190**] revealed multivessel disease with elevated
pulmonary capillary wedge pressure of 34. He was transferred
to the Coronary Care Unit without any intervention at that
time, where he was aggressively diuresed with intravenous
Lasix with a subsequent relief of his shortness of breath
symptoms. Secondary to decreased blood pressures while in
the Coronary Care Unit, his dose of beta blocker was lowered,
and his blood pressure subsequently normalized.
The patient was then transferred to the C-MED Service for
repeat cardiac catheterization with definitive intervention
and perfusion study.
PAST MEDICAL HISTORY:
1. Coronary artery disease with acute myocardial infarction
complicated by ventricular fibrillation arrest in [**2128**];
status post coronary artery bypass graft in [**2128**] of the
saphenous vein graft to the left anterior descending artery.
A redo coronary artery bypass graft in [**2132**] with saphenous
vein graft to right coronary artery and saphenous vein graft
to first diagonal. A redo coronary artery bypass graft in
[**2159-8-16**] with left internal mammary artery to the left
anterior descending artery, radial to posterior descending
artery, saphenous vein graft to first diagonal, saphenous
vein graft to first obtuse marginal to second obtuse
marginal.
2. Hepatitis B (acquired through a blood transfusion).
3. Hypertension.
4. Left bundle-branch block.
5. Congestive heart failure by echocardiogram with 15%
ejection fraction.
6. Mitral regurgitation (4+ by echocardiogram in [**2159-8-16**]).
ALLERGIES: The patient states he has a PENICILLIN allergy
which causes a rash. He also states that MORPHINE drops his
blood pressure significantly. CODEINE, SULFA, IODINE, and
new allergy to RAPID INTRAVENOUS BENADRYL INFUSION; stating
that he had throat tightness.
MEDICATIONS ON TRANSFER: Enteric-coated aspirin 325 mg p.o.
q.d., Lopressor 25 mg p.o. b.i.d., captopril 12.5 mg p.o.
t.i.d., Lipitor 20 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
Plavix 75 mg p.o. q.d., Colace 100 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs revealed a temperature of 98, blood pressure
was 100/64, heart rate was 89, respiratory rate was 18. He
had an oxygen saturation of 95% on room air. In general, he
was a very pleasant man, sitting in a chair, in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed no carotid bruits that were identifiable. No
jugular venous distention was appreciated. His neck was
supple, and sclerae were anicteric. Cardiovascular
examination revealed a diminished first heart sound, second
heart sound, and a possible third heart sound gallop heard
occasionally. Tachycardic with a [**2-21**] to 3/6 systolic
ejection murmur heard best at the left upper sternal border
and right upper sternal border radiating to the carotids.
The murmur was heard over the entire precordial region.
There was also a possible diastolic component as well. Lung
examination revealed lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended, with present bowel sounds. The extremities
revealed 1+ lower extremity edema, cool, but well perfused,
with 1 to 2+ pedal pulses bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
findings on transfer revealed the patient had a white blood
cell count of 4.3, hematocrit was 34.1, platelets were 178.
Sodium was 141, potassium was 4, chloride was 106,
bicarbonate was 25, blood urea nitrogen was 21, creatinine
was 0.6, with a blood glucose of 100.
HOSPITAL COURSE: On hospital day seven, the patient was
returned to the cardiac catheterization laboratory for
definitive treatment of his substernal chest discomfort.
His first diagnostic cardiac catheterization revealed an 80%
stenosis at the saphenous vein graft to obtuse marginal jump
graft at the touchdown of the second obtuse marginal. A
functional assessment of the stenosis was performed using a
pressure wire showing a pressure gradient across the stenosis
decreased from 0.79 to 0.69. The patient underwent
successful percutaneous transluminal coronary angioplasty
plus stent of the saphenous vein graft to first obtuse
marginal to second obtuse marginal at the touchdown of the
second obtuse marginal segment. Overall, he tolerated the
procedure quite well.
On arrival to the floor, the patient was somewhat dizzy and
moderately hypotensive; however, this quickly resolved
without any intervention needed. Subsequent electrolytes,
and hematocrits, and cardiac enzymes were all stable and
within normal limits.
On hospital day eight, the patient was chest pain free, doing
quite well, fully ambulatory, and without any symptoms of
shortness of breath. He was felt to be stable for discharge
home at this time.
During his hospital course, the patient did have one episode
of nonsustained ventricular tachycardia (a 6-beat run). He
was asymptomatic during this episode and spontaneously
converted to a normal sinus rhythm. No further intervention
was necessary at this time.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] in his outpatient cardiac clinic as needed for
adjustment of his blood pressure medications.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Zestril 5 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. (times 30 days).
4. Lopressor 25 mg p.o. b.i.d.
5. Lipitor 20 mg p.o. q.d.
6. Sublingual nitroglycerin as needed for chest pain.
DISCHARGE STATUS: Discharge status was to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post three coronary
artery bypass grafts.
2. Status post percutaneous transluminal coronary
angioplasty plus stent to the saphenous vein graft to first
obtuse marginal to second obtuse marginal at the second
obtuse marginal touchdown.
3. Hepatitis B.
4. Hypertension.
5. Left bundle-branch block.
6. Congestive heart failure by echocardiogram with 15%
ejection fraction.
7. Mitral regurgitation (4+ on echocardiogram).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Doctor Last Name **]
MEDQUIST36
D: [**2159-10-3**] 16:12
T: [**2159-10-9**] 11:26
JOB#: [**Job Number 105749**]
ICD9 Codes: 4280, 4111, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4534
} | Medical Text: Admission Date: [**2186-11-28**] Discharge Date: [**2186-12-2**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 31348**] is an
eighty-five-year-old woman admitted to an outside hospital
with an MI, recent increase in dyspnea on exertion and
fatigue and occasional chest pain at rest times one day. She
was transferred [**Hospital1 18**] for cardiac catheterization back in
[**2186-10-16**]. Catheterization at that time revealed
moderate CAD and severe AS with an aortic valve area of 0.61.
She was then referred to Cardiac Surgery for aortic valve
replacement plus or minus CABG.
PAST MEDICAL HISTORY: Past medical history is significant for
hypertension, hypercholesterolemia, hypothyroidism, irritable
bowel syndrome, syncope and rectal prolapse.
PAST SURGICAL HISTORY: Past surgical history is significant
for hysterectomy and colostomy.
MEDICATIONS: Medications prior to admission include, Levoxyl
50 mg every day, Univasc 15 mg every day, Lipitor 10 mg every
day, Atenolol 25 mg every day, Detrol 4 mg every day, aspirin
325 mg every day.
ALLERGIES: She is allergic to Penicillin, which causes a
rash.
SOCIAL HISTORY: Widowed, lives alone, very active, no tobacco
and no alcohol use.
PHYSICAL EXAMINATION: Neurologic, grossly intact. Pulmonary,
bibasilar crackles. Cardiac, regular rate and rhythm with a
grade IV/VI systolic ejection murmur. Abdomen is well healed
surgical scar, colostomy and soft, nontender with positive
bowel sounds. Extremities are warm with no edema and equal
pulses bilaterally.
LABORATORY DATA: Carotid ultrasound showed tortuous bilateral
carotids with 60% to 69% occlusions and normal antegrade
vertebrals. Echo showed an ejection fraction of 40% with an
aortic valve area of 0.7, peak gradient of 84 and 1 to 2+ MR.
Laboratory data, white blood cell count 6.1, hematocrit 30.8,
platelets 161,000. INR 2.0, PTT 140.4. Sodium 140, potassium
4.6, chloride 105, CO2 29, BUN 25, creatinine 0.8, glucose
96, AST 99. CPK 916. ALT 33. Alkaline phosphatase 47. Total
bilirubin 0.7. Chest x-ray showed small bilateral effusions.
HOSPITAL COURSE: The patient was discharged to home following
her cardiac catheterization and returned to [**Hospital1 **] for aortic
valve replacement on [**2186-11-28**], as a postoperative
admission. As stated, the patient was directly admitted to
the Operating Room where she underwent an aortic valve
replacement. Please see the OR report for full details and
summary as she had an AVR with a number 19 [**Company 1543**]
pericardial valve. Her bypass time was 79 minutes and the
cross clamp time was 53 minutes. The patient tolerated the
operation well and was transferred from the Operating Room to
the Cardiothoracic Intensive Care Unit. At the time of
transfer, the patient had Neo-Synephrine infusion. Her mean
arterial pressure was 65 and she was A paced at a rate of 86
beats per minute. The patient did well in the immediate
postoperative period. Her anesthesia was reversed and she was
weaned from the ventilator, however, she failed her initial
attempt at extubation. She therefore, was placed back on the
ventilator for a short period of rest and was reweaned and
successfully extubated four hours later. On postoperative day
number, the patient remained hemodynamically stable without
any cardioactive IV medications. Her chest tubes and central
venous lines were removed and she was transferred to the
floor. Over the next several days, the patient had an
uneventful postoperative course. She worked with the nursing
staff and physical therapy staff to increase her activity
level and on postoperative day number three, it was decided
that the patient would be stable and ready to be transferred
to rehabilitation on the following morning for continued
postoperative care. At the time of this dictation, the
patient's physical examination is as follows, vital signs,
temperature 99.0 F, heart rate 79 sinus rhythm, blood
pressure 130/70, respiratory rate 20, O2 saturation 97% on
room air. Weight preoperatively, 63.4 kilos, at discharge
69.6 kilos. Laboratory data, white blood cell count 13.2,
hematocrit 34.8, platelets 71,000. Sodium 137, potassium of
3.4, chloride 98, CO2 32, BUN 15, creatinine 0.7, glucose 89.
Physical examination, alert and oriented times three. Moves
all extremities. Follows commands. Respiratory, diminished
breath sounds in the bases, otherwise, clear to auscultation.
Cardiac, regular rate and rhythm. Sternum is stable. Incision
with Steri Strips, open to air, clean and dry. Abdomen is
soft, nontender with positive bowel sounds. Colostomy is
intact. Extremities are warm and well perfused with no edema.
DISCHARGE MEDICATIONS: The patient's discharge medications
include, Lasix 20 mg every day times ten days, potassium 20
milliequivalents every day times ten days, Colace 100 mg
twice a day, enteric coated aspirin 325 every day,
Levothyroxine 50 mcg every day, Atorvastatin 10 mg every day,
Tolterodine 2 mg twice a day, Antiprotozoal 40 mg every day,
Metoprolol 50 mg twice a day, Levofloxacin 500 mg every
twenty-four hours times two days, Percocet 5/325 one to two
tablets every six hours PRN.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES: 1) AS, status post aortic valve
replacement with a number 19 [**Company 1543**] pericardial valve. 2)
Hypertension. 3) Hypercholesterolemia. 4) Hypothyroidism. 5)
Irritable bowel syndrome. 6) Syncope. 7) Rectal prolapse. 8)
Status post hysterectomy. 9) Status post colostomy. The
patient is to be discharged to rehabilitation. She is to have
follow-up with her primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] in
three weeks and follow-up with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 9076**]
MEDQUIST36
D: [**2186-12-1**] 05:55
T: [**2186-12-1**] 18:39
JOB#: [**Job Number 31349**]
ICD9 Codes: 4241, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4535
} | Medical Text: Admission Date: [**2200-6-19**] Discharge Date: [**2200-6-25**]
Date of Birth: [**2128-1-13**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
gentleman with atrial fibrillation (on Coumadin) who
presented to [**Hospital 882**] Hospital on [**2200-6-17**] with left
hand clumsiness.
On the day of admission, the patient was having trouble with
his proximal arm; such as putting his clothes on. He also
complained of facial and hand twitching. No headache. A
head computed tomography showed a left parietal bleed. He
was transferred to [**Hospital1 69**] for
further management.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, he was afebrile, his blood pressure was 130/80,
his heart rate was 105 (he was in atrial fibrillation), and
respiratory rate was 16. He had no complaints of dizziness.
His chest was clear to auscultation bilaterally.
Cardiovascular examination revealed he was in irregular
rhythm, atrial fibrillation. He had some right upper
extremity weakness. He had some right facial weakness. His
speech was fluent. He was alert and attentive. Pupils were
equal, round, and reactive to light. His abdomen was soft,
nontender, and nondistended. Positive bowel sounds.
HOSPITAL COURSE: He was admitted to the Intensive Care Unit
with a left parietal bleed and right-sided hemiparesis.
He was monitored in the Intensive Care Unit. He was seen by
the Stroke Service. They suggested doing a magnetic
resonance imaging scan to rule out amyloid angiopathy. With
a history of cancer, the magnetic resonance imaging with
contrast to rule out underlying lesions. The magnetic
resonance imaging was completed, and there was some
superficial surrounding enhancement around the hemorrhage,
and an underlying lesion could not be ruled out secondary to
the fact that there was so much blood that it was equivocal.
The patient was transferred out of the unit after a repeat
head computed tomography was stable with no further bleeding.
He was seen by Physical Therapy and Occupational Therapy and
found to require rehabilitation. He continued to awake,
alert, and oriented times three and was moving his left side
well. He continued with a right facial droop and right hand
and leg weakness and was a candidate for acute
rehabilitation.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Lasix 40 mg p.o. once per day.
2. Dilantin 100 mg p.o. three times per day.
3. Zantac 150 mg p.o. twice per day
4. Metoprolol 50 mg p.o. twice per day.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in one month for a repeat magnetic
resonance imaging scan at that time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-6-24**] 13:57
T: [**2200-6-24**] 14:33
JOB#: [**Job Number 40964**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4536
} | Medical Text: Admission Date: [**2148-12-18**] Discharge Date: [**2149-1-9**]
Date of Birth: [**2148-12-18**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname 46000**] is a former 34 [**1-3**] week female
twin #1 of two admitted for prematurity.
MATERNAL HISTORY: 34-year-old gravida 3, para [**11-29**] woman for
past OB notable for full term cesarean section in [**2143**] and
SAB in [**2145**]. Prenatal screens, B+, Coombs negative.
Hepatitis B surface antigen negative. RPR non reactive.
Rubella immune. GBS unknown.
PREGNANCY HISTORY: Estimated date of confinement [**2149-1-27**] for
EGA of 34 2/7 weeks on day of delivery. Triplet IVF
pregnancy reduced to twin gestation. Course subsequently
benign until oligohydramnios noted in twin #2 with slight
fetal weight discordance of approximately 200 gm. Proceeded
to repeat cesarean section for oligo and breech presentation.
No labor, although some mild contractions were noted.
Rupture of membrane at delivery yielding clear amniotic
fluid, no fetal tachycardia, distress of maternal fever.
Betamethasone not administered. No intrapartum antibiotic
prophylaxis.
NEONATAL COURSE: Infant vigorous at delivery orally and
nasally bulb suctioned, dried, subsequently pink and in no
distress in room air. Apgars 8 at one minute and 8 at five
minutes. Transported to the NICU uneventfully.
PHYSICAL EXAMINATION: On admission, well appearing infant
with exam consistent with 34 weeks gestation, birth weight
2155 gm, 50th percentile, head circumference 31?????? cm, 50th
percentile, length 44 cm, 25th-50th percentile. Heart rate
164, respiratory rate 44, blood pressure 49/32 with a mean of
42. FAO2 99% in room air. Temperature 98.7. Head, ears,
nose and throat, anterior fontanels soft and flat, non
dysmorphic, palate intact. Mouth normal. No nasal flaring.
Chest, no retractions, good bilateral breath sounds, no
crackles. Cardiovascular, well perfused, regular rate and
rhythm. Femoral pulses normal. S1 and S2 normal. 1/6 SEM
lower left sternal border without radiation. Abdomen soft,
non distended, no organomegaly, no masses, anus patent. GU,
normal female preterm genitalia. CNS active, alert,
responsive to stim, tone AGA, moving all limbs symmetrically,
suck, gag, moro normal. Integumentary normal.
Musculoskeletal normal spine, limbs, hips and clavicles.
HOSPITAL COURSE:
1. Respiratory: Baby remained in room air without any
respiratory distress, has had several desaturations,
occasionally requiring blow by O2, did not require
Methylxanthine treatment. At the time of discharge has been
free of apnea for greater than 5 days. Baseline
respiratory rate 40-50, bilateral breath sounds clear and
equal, no issues.
2. Cardiovascular: Baby had a soft murmur that persisted
for approximately 48 hours. She did not require any pressor
support. She no longer has a murmur. Baseline heart rate
130's to 140's with systolic blood pressures in the 50's to
60's, diastolics in the 30's and the means in the 40's to
50's. She has no cardiovascular issues.
3. Fluids, Electrolytes & Nutrition: Baby initially was npo
with peripheral IV fluid. She had stable dextrose sticks.
Enteral feedings were introduced on day of life #1. She
advanced to full enteral feeds of PE 24. Planned to
discharge on ad lib feeding on Enfamil 24. Baby did require
some gavage feedings which are no longer indicated. Baby is
voiding and stooling without issue. Electrolytes were not
done during this admission as baby was enterally feeding
without issue.
The infant did show immature feeding skills with
dyscoordination and desaturations. This is now improved. Last
desaturation requiring blow-by oxygen was [**2149-1-4**] and last
desaturation was greater than 48 hours prior to discharge.
Mother is comfortable feeding the baby and responds to her
cues appropriately.
4. Gastrointestinal: Baby had a bilirubin on day of life #2
which was 5.5/0.3. She did not require phototherapy.
5. Hematology: Baby did not require any blood transfusions
during this admission. Admission hematocrit was 48.4, repeat
hematocrit on day of life #3 was 44.4.
6. Infectious Disease: On admission, baby had a culture and
a CBC sent because of prematurity and had a white count of 13
with 27 polys, 0 bands. Platelet count 341,000 with 29
nucleated red blood cells. She was started on Ampicillin and
Gentamycin for 48 hours. At 48 hours baby was clinically
well. Cultures were negative and antibiotics were
discontinued. On day of life #3 she had an increase in
desaturations and apnea and a repeat blood culture and CBC
were sent. She was not started on antibiotics. The CBC was
benign with a white count of 13.1, 55 polys, 0 bands, 29
lymphs, platelet count 360,000. Cultures remained negative
and she has had no further issues with infection.
7. Neurology: Based on gestational age of greater than 34
weeks, she did not require a head ultrasound. Physical exam
is appropriate for gestational age.
8. Sensory: Audiology screening was passed.
9. Ophthalmology: Exam not indicated based on gestational
age greater than 32 weeks.
10. Psychosocial: Parents have been visiting. Her brother
[**Name (NI) **] was discharged prior to [**Name (NI) 46001**] and they look forward to
having their whole family together again at home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
PRIMARY PEDIATRICIAN: DR. [**First Name (STitle) **] [**Doctor Last Name **], [**Telephone/Fax (1) 37814**].
CARE RECOMMENDATIONS: Continue ad lib feedings of E24 with
iron. Medications none at the time of discharge. Carseat
positioning passed. State newborn screens were sent on [**12-23**],
and on [**2149-1-1**].
Immunizations received: Hepatitis B vaccine on [**12-20**] and
Synagis on [**2148-12-28**]. Immunizations recommended: Synagis RSV
prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 958**]
for those infants who meet any of the following three
criteria: 1) Born at less than 32 weeks; 2) Born between 32
and 35 weeks with plans for DayCare during RSV season, with a
smoker in the household, or with preschool siblings; or 3)
with chronic lung disease. Influenza immunization should be
considered annually in the Fall for preterm infants with
chronic lung disease once they reach 6 months of age. Before
this age, the family and other caregivers should be
considered for immunization against influenza to protect the
infant.
FOLLOW-UP: Scheduled with Dr. [**Last Name (STitle) 1728**], primary care physician,
[**Name10 (NameIs) **] [**Name11 (NameIs) 2974**], [**2149-1-10**]. Visiting nurse will be visiting this
family.
DISCHARGE DIAGNOSIS: Former 34 [**1-3**] week twin female, status
post rule out sepsis with antibiotics, status post apnea and
desaturations of prematurity.
Of note: Baby has a diaper rash that is improving with
application and protection of Critic-Aid.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2148-12-31**] 18:52
T: [**2148-12-31**] 19:44
JOB#: [**Job Number 46002**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4537
} | Medical Text: Admission Date: [**2180-5-24**] Discharge Date: [**2180-6-6**]
Date of Birth: [**2114-8-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Rigid Bronchoscope
History of Present Illness:
65 yo F COPD, recurrent PNA, non small cell lung cancer s/p
chemo and radiation in [**2175**], OSA, worsening pulmonary function,
increasing O2 requirement leading to intubation today at OSH,
sputum growing aspergillosis, and on flex bronchoscopy a fungal
ball was visualized in left main stem bronchus. At OSH she was
admitted on [**2180-5-10**] for acute onset of respiratory distress.
She was treated for bilateral lower lobe pneumonia with
ceftriaxone and azithyromycin later changed to intravenous
vancomycin and ceftazidime as well for a COPD exacerbation with
IV steriods and combivent nebs. She worsened and was put on high
flow O2, she coughed a whitish mass that was shown to be
Aspergillus by histopathology. She was placed on PO
voriconazole. She then had worsening respiratory function and
was switched to IV voriconazole. She continued wheezing and was
intubated on [**5-23**] and a felxible bronchoscopy was performed that
showed extensive endobroncial whitish mass obsturcting mainly
the Left main stem bronchus aparently biopsies of this were
consistent with the specimen that was coughed up. She also had a
CT Angio in order to determine if a PE was contributing to her
symptoms. That scan showed no PE and extensive bilateral lower
lobe infiltrates. She was transferred to [**Hospital1 18**] where she had
been previously treated in the MICU for MRSA PNA with bilateral
infiltrates and COPD in [**2180-4-10**].
Past Medical History:
- Stage IIIb lung cancer diagnosed 3 years ago now s/p chemo &
XRT
- Asthma/COPD
- [**Doctor Last Name 933**] disease s/p RAI
- GERD s/p Nissen fundoplication
- Hypertension
- Sinusitis
- type 2 diabetes
- Depression
- Anal fissure
- Tonsillectomy
- Hemorrhoidectomy
- Pilonidal cyst excision
- Ear plastic surgery
- Appendectomy
Social History:
- Retired
- 30 pack year smoker, quit in [**2157**]
- No EtOH use
- She is single and lives with her sister
Family History:
- Mother: HTN, TTP, goiter
- Father: [**Name (NI) 3495**] disease, CVA, lung cancer
- Sister: MS
- Brother: Psychiatric illness
Physical Exam:
Physical exam on admission to MICU:
Intial Vital Signs: T: 97.6 BP:119/91 P:57 R:15 O2:99%
General: Intubated, sedated and paralyzed
HEENT: Sclera anicteric, ET tube in place, pupils 1mm
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Scatterred Wheezes, diminished at bases.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, mild edema in legs
Neuro: Intubated, sedated, and paralyzed
DISCHARGE PHYSICAL:
Vital Signs: T98.4 BP 137/75 P88 R22 O2 95 on 3L
General: obese female in NAD
HEENT: Sclera anicteric, no conjunctival pallor, MMM
Neck: supple, no LAD
CV: distant heart sounds, however no murmurs appreciated this
AM, regular rate
Lungs: prominent inspiratory wheezes worse at the base with
improved end-expiratory wheezes bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, minimal edema in Lower extremities;
upper extremities with 2+ edema.
Neuro: A+O x 3
Pertinent Results:
[**2180-5-24**] 01:30AM WBC-26.2*# RBC-4.45 HGB-11.1* HCT-35.2*
MCV-79* MCH-24.9* MCHC-31.5 RDW-18.3*
[**2180-5-24**] 01:30AM NEUTS-87* BANDS-2 LYMPHS-2* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2180-5-24**] 01:30AM CORTISOL-16.0
[**2180-5-24**] 01:30AM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-4.6*
MAGNESIUM-2.0
[**2180-5-24**] 01:30AM GLUCOSE-205* UREA N-44* CREAT-1.1 SODIUM-133
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
[**2180-5-24**] 01:37AM LACTATE-1.4
IMAGING:
CT chest [**2180-6-2**]
IMPRESSION:
1. Interval improvement in bibasilar consolidation, and
multifocal solid and ground-glass nodules from [**5-22**]. There
is redemonstration of mild
bronchiectasis, and marked irregular tracheal and bronchial wall
thickening, with a large amount of inspissated debris within the
left main stem bronchus and its tributaries. Soft tissue
situated in the subcarinal location is
unchanged and may represent lymph node.
2. Small airways disease with airtrapping. Post-radiation
changes to the left upper lobe are constant.
LABS ON DISCHARGE:
[**2180-6-6**] 11:00AM BLOOD WBC-8.0 RBC-3.77* Hgb-9.7* Hct-30.4*
MCV-81* MCH-25.7* MCHC-31.9 RDW-19.8* Plt Ct-140*
[**2180-6-6**] 11:00AM BLOOD Glucose-188* UreaN-34* Creat-1.2* Na-135
K-3.4 Cl-98 HCO3-26 AnGap-14
[**2180-6-6**] 11:00AM BLOOD ALT-111* AST-44* AlkPhos-176* TotBili-0.4
[**2180-6-6**] 11:00AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.7
[**2180-5-29**] 06:34AM BLOOD TSH-6.1*
B-GLUCAN
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
100 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
Brief Hospital Course:
65 yo F COPD, recurrent PNA, non small cell lung cancer s/p
chemo and radiation in [**2175**], OSA was found to have invasive
aspergilloma complicated by respiratory failure requiring
intubation.
Active Diagnoses
#Respiratory failure-improved.
Multifactorial etiologies of respiratory failure requiring
intubation including COPD, PNA, and Invasive Aspergilloma.
Patient required bronchoscopy for removal of obstruction as well
as respiratory support with mechanical ventilation. After being
successfully extubated, patient was gradually weaned to 3L
supplemental O2.
#Invasive Aspergilloma: Rigid bronchoscopy with debridment
showed large fungus ball obstructing left mainstem bronchus.
Pathology proven aspergillus along with positive B-glucan
indicative of invasive aspergilloma. Started on Voriconazole IV
and switched to po form to avoid nephroxoticity. Pt. then
developed worsening LFTs and was switched to Ambisome IV, with
subsequent improvement of her LFTs. She is to continue ambisome
until [**2180-7-7**].
#COPD exacerbation: PT with chronic COPD, requiring high dose
steroids for nearly 2 months. Patient has been tapered to
steroid dose of 15mg PO daily. Will continue at 15mg PO daily
for 5 total days, then 10mg for 5 days, then 5mg for 5 days,
then discontinue. Patient was switched from albuterol and
ipratropium nebulizers to MDIs, with good control.
#HCAP: Pt found to have PNA at OSH, completed 14 days of
antibiotic therapy in house for suspected HCAP.
#Venous acccess: Non-occlusive thrombosis noted in left upper
extremity after difficulty using left PICC line. Right PICC was
attempted, however was only able to get midline, which
subsequently did not draw and then did not allow pushing fluids.
At discharge, a midline was placed.
#Depression: Patient had flat affect and psychomotor retardation
throughout stay in hospital. It is highly advised that patient
be followed up for depression
-continue citalopram.
#Anxiety: patient was anxious daily during her hospital stay,
sometimes causing tachycardia. Patient responded well to ativan
0.5mg IV. Would benefit from outpatient management of anxiety.
Chronic Diagnoses
#HTN
-Pt was hypotensive during the course of her MICU stay likely
[**12-30**] effects of sedation from propofol during intubation.
Levophed was required. Cortisol levels normal. Anti
hypertensives were not required in house. Patient should be
re-evaluate for hypertension as an outpatient.
#Stage IIIb Non small cell lung cancer
-Pt diagnosed 3 years ago now s/p chemo & XRT. NO acute relapse
noted in this admission.
#OSA:
-After extubation, pt continued to use CPAP nightly as she does
at home.
#Diabetes Mellitus:
-Pt's po meds were held, she was managed on SSI. She was
stabilized on 35 units lantus with sliding scale on top.
#HLD
-continued on simvastatin.
#Hypothyroid
Pt remained stable, continued on outpatient Levothyroxine.
#GERD
Pt continued omeprazole.
TRANSITIONAL ISSUES
-Pulmonologist should follow up on IgE levels pending in
hospital for possible allergic bronchopulmonary aspergillosis.
Medications on Admission:
Medications from OSH:
citalopram 20mg PO
doxycycline 100mg iv
lovenox 80mg
combivent
propofol for vent
nystatin [**Numeric Identifier 78144**] units oral
pantoprazole iv 40mg iv
mom[**Name (NI) 6474**] 1 [**Name2 (NI) **]
lorazepam 1-3mg for vent
levothyroxine 150mcg daily po
insulin detemir 20 units daily subq
methylprednisone 40mg daily iv
Voriconazole 500mg [**Hospital1 **] iv
trimethoprim/sulfamethox- iv 500mg Q8Hr
amlodipine 5mg daily po
Valsartan 80 daily po
Simvastatin 20 daily po
Medications from MICU [**4-20**]
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Xopenex Inhalation
6. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day. (takes 2 tabs on sunday)
7. mom[**Name (NI) 6474**] 50 mcg/Actuation [**Name (NI) 37062**], Non-Aerosol Sig: [**11-29**]
Nasal once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
as directed Inhalation as directed.
11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
14. fluticasone 50 mcg/Actuation [**Month/Day (2) 37062**], Suspension Sig: One (1)
15. Januvia 50 mg qd
16. Diovan 80 mg qd
17 levemir 38 units qpm
Discharge Medications:
1. Albuterol Inhaler 3 PUFF IH Q4H:PRN wheezing
please use spacer with MDI.
2. Citalopram 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Ambisome 450 mg IV Q24H
Please space by 2 hours from platelet transfusions.
8. Guaifenesin [**4-6**] mL PO Q6H:PRN cough
9. Lorazepam 0.5 mg PO Q8H:PRN anxiety/ dyspnea
hold for sedation, RR<10
10. GlipiZIDE 10 mg PO BID
11. Simvastatin 20 mg PO DAILY
12. traZODONE 200 mg PO HS:PRN insomnia
13. PredniSONE 15 mg PO daily Duration: 4 Days
14. PredniSONE 10 mg pO DAILY Duration: 5 Days Start: After 15
mg tapered dose.
15. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg
tapered dose.
16. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary diagnosis: respiratory failure, aspergillosis
Secondary diagnosis: acute kidney injury, anxiety, COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 29425**],
You were treated at [**Hospital1 18**] for respiratory distress and invasive
aspergillosis. While here, you required having a tube to
breath, and having a procedure where we were able to take out
things that were blocking the airway of your lung. We started
you on a medication to kill the infection, however it made your
liver numbers worse. We then stopped that medication and
started a different one, and your liver numbers improved.
As you recovered, you have required less oxygen over time. You
should continue to take the medications we prescribed you, and
follow up with your primary care doctor in [**1-31**] days and your
pulmonologist within 1 week.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] P.
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 59250**]
Phone: [**Telephone/Fax (1) 34574**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Department: Pulmonary
Address: [**Location (un) 80096**], [**Apartment Address(1) 31103**], [**Location (un) **],[**Numeric Identifier 39854**]
Phone: [**Telephone/Fax (1) 80097**]
Appointment: Tuesday [**2180-6-13**] 2:45pm
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2180-6-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2180-6-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2180-7-20**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2180-6-6**]
ICD9 Codes: 486, 5849, 4019, 311, 2724, 2449, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4538
} | Medical Text: Admission Date: [**2138-8-3**] Discharge Date: [**2138-8-5**]
Date of Birth: [**2096-8-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 41-year-old male who
presented to the Emergency Room with three days of sore
throat. He noted that there was someone at work who about
four days ago had had these similar symptoms. His sore
throat has been increasing in severity over the last several
days with increasing dysphagia over the last 24 hours and he
has not been able to swallow secondary to pain. He notes
increased difficulty managing his secretions and increasing
hoarseness. The patient notes feeling chills but was not
able to take his temperature. He denied sweats, no nausea,
vomiting, diarrhea or chest pain, no abdominal pain, no
shortness of breath, no difficulty breathing. No cough, no
sputum, no nasal congestion. In the Emergency Room the
throat was benign on exam but the lateral neck films showed
epiglottal swelling so ENT was consulted and they did
fiberoptic laryngoscopy which showed swelling of the
epiglottis, subepiglottis and supraglottal tissues although
the airway was patent and the vocal cords seemed okay.
PAST MEDICAL HISTORY: 1) Diabetes mellitus diagnosed in [**2121**]
with history of DKA, insulin dependent. 2) Hypertension, no
medications. 3) Ethanol abuse. 4) Question of sarcoid.
ALLERGIES: No known drug allergies.
MEDICATIONS: NPH insulin 42 units subcutaneously q a.m., 28
units subcutaneously q p.m., Regular Insulin 8 units
subcutaneously [**Hospital1 **].
FAMILY HISTORY: Mother had diabetes, niece has diabetes, no
coronary artery disease, no hypertension, no cancer, no liver
disease, no renal disease in the family.
SOCIAL HISTORY: Occasional alcohol use. He used tobacco in
the past but has not used tobacco in many years. He used
marijuana as recently as last week and has distant history of
Cocaine use. He lived with his girlfriend and changes tires
for a living.
PHYSICAL EXAMINATION: On exam his temperature was 98.9,
heart rate 91, blood pressure 160/76, respiratory rate 16,
oxygen saturation 95-98% on room air. In general he was in
no acute distress lying flat in bed. HEENT: Pupils were
equal, round and reactive to light. Discs were sharp,
extraocular movements intact. His sclera were anicteric,
tympanic membranes were clear bilaterally. Neck was supple
and there was an anterior fullness felt in the neck. There
was no lymphadenopathy. Respiratory clear to auscultation
bilaterally. Cardiovascular, regular rate and rhythm, no
murmurs, rubs or gallops. Abdomen, normoactive bowel sounds,
soft, nontender, non distended, no hepatosplenomegaly.
Extremities, no clubbing, cyanosis or edema. DP and
posterior tibial pulses were 2+ bilaterally. Neuro, alert
and oriented times three, grossly non focal. Skin,
folliculitis seen on the back and chest with closed
comedones.
LABORATORY DATA: White count 6.3, hemoglobin 16.2,
hematocrit 45.5, platelet count 216,000. Chem 7 was
remarkable for a glucose of 299. LFTs, AST 25, ALT 37,
alkaline phosphatase 156, total bilirubin 1.8. Neck x-ray
showed thumb printing on the lateral but no other soft tissue
abnormalities. Lung apices were clear. EKG showed normal
sinus rhythm at rate of 90, normal axis, normal intervals,
biphasic T waves in lead 3 which was new from the last EKG
done in 7/99. J point was increased in leads V1 to V4 with
ST elevation of 0.5 mm in leads 2, V5 and V6, however, this
was no change from [**8-/2136**].
IMPRESSION: This 41-year-old male with diabetes and
hypertension with history of alcohol abuse presenting with
sore throat, hoarseness and dysphagia found to have
epiglottal swelling.
HOSPITAL COURSE:
1. Infectious Disease: The patient was presumed to have
epiglottitis on the basis of his symptoms. The thumb
printing on lateral neck x-ray and on direct visualization of
the soft tissues by laryngoscopy performed by ENT consult
service. He improved dramatically with Unasyn which was
changed to Augmentin 500 mg po tid as well as pulse course of
Solu-Medrol.
2. Endocrine: He had increased glucose and decreased bicarb
suggesting a possibility of mild diabetic ketoacidosis, but
this was managed with an insulin sliding scale and an insulin
drip was never needed.
3. Gastrointestinal: In the setting of an increased
alkaline phosphatase in a patient with possible ethanol
abuse, we checked right upper quadrant ultrasound to rule out
cholestasis. This ultrasound was essentially normal.
Follow-up was arranged for the patient at the ENT unit for an
appointment at 8:30 a.m. on [**2138-8-12**] and an appointment with
the podiatry clinic at 9:10 a.m. on [**2138-8-7**]. He was told to
follow-up with his primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 105508**] within two
weeks.
DISCHARGE MEDICATIONS: Prior dose of insulin which was NPH
insulin 42 units subcu q a.m., 28 units subcu q p.m. and
Regular insulin 8 units subcu q a.m. and 8 units subcu q p.m.
as well as a 10 day course of Augmentin 500 mg po bid.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: He was sent home.
DISCHARGE DIAGNOSIS:
1. Epiglottitis.
2. Diabetes mellitus.
DR [**Last Name (STitle) **] [**Name (STitle) 198**] 11.841
Dictated By:[**Last Name (NamePattern4) 105509**]
MEDQUIST36
D: [**2138-8-8**] 15:17
T: [**2138-8-9**] 09:32
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4539
} | Medical Text: Admission Date: [**2151-5-6**] Discharge Date: [**2151-5-14**]
Date of Birth: [**2097-10-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Bee Pollens
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization x2
PCI to LAD and L-Cx
History of Present Illness:
53 year old male with hypertension p/w anterior STEMI and new
RBBB now s/p proximal LAD stent. Pt was in his USOH, working at
home in the morning. He was sitting at his desk when he started
to feel "uncomfortable" without specific complaints. Pt lied on
the sofa for about 15minutes without relief. He went upstairs
from his basement where he was working and started to c/o severe
Chest pain and significant SOB. Per pt's mother, pt lied on the
couch then lied on the floor as he could not get comfortable.
[**Name (NI) 1094**] mother called 911 and EMS arrived within 30minutes of onset
of severe CP. Pt did not take any medications for his pain. Per
EMS EKG strip noted ST elevations and brought to [**Hospital1 18**] ED. In ED
found to have new RBBB, ST elevations in V1-V6, ST depressions
in II, III, aVF. Pt c/o [**9-28**] CP in ED, received ASA, NTG x2 and
dropped his BP to 90/P, received 500cc IVF bolus with
improvement in BP to 138/102. He was started on Hep gtt, loaded
with Plavix 600mg and 4mg Morphine IV with symptomatic relief.
Pt was taken to the cath lab for immediate intervention.
In cath lab, pt found to have 90% thrombotic LAD lesion, had
3.0x18 cypher stent. Also with 80% mid-circumflex lesion which
was not stented. CO 3.23, CI 1.92. Wedge of 31, RA 11, PA 51/30
mean 39. O2 sats dropped to 76% on 6 liters, got lasix 20mg IV.
Sats improved, but htn, started on ntg gttp. No uop, foley
placed. Vagaled with foley placement, became hypotensive, ntg
d/c'd and given atropine. He responded, and then became htn
again, started back on low-dose ntg.
.
Pt with one prior h/o CP about 2.5 years ago while visiting
[**Country 11150**]. CP at that time was very minimal compared to current
presentation. Per physicians in [**Country 11150**] work up no CAD, negative
EKG. Pt has not had CP since then until current presentation. Pt
has a very sedentary lifestyle with minimal ambulation/activity.
He denies any DOE/SOB at rest, no orthopnea, no PND.
Past Medical History:
- borderline hypercholesterolemia
- hypothyroidism
- hypertension
Social History:
Social History: Married, lives at home with wife and [**Name2 (NI) **].
Works at home as financial analyst. No tobacco, occasional
EtOH 1-2 drinks per week. Denies any other drug use.
Family History:
Family History: uncles with CAD -MIs at age 50 & age 75 with
CABG; [**Name2 (NI) **] with DM, HTN; aunt- breast ca
Physical Exam:
Physical Exam:
VS- P=93 BP= 103/70 R= 19 97% on 2l
Gen- in NAD
HEENT- EOMI, o/p clear
CV- RR, no m/r/g
Pulm- CTA=bil
Abd- S/NT/ND
Ext- W&D, 2+ radial/DP pulses
Neuro- non-focal
Pertinent Results:
[**2151-5-6**] ECG:
Sinus rhythm with ventricular premature depolarizations. Right
bundle-branch block. Left axis deviation. Left anterior
fascicular block. Anterior wall myocardial infarction.
.
[**2151-5-6**] Cath:
COMMENTS:
1. Selective coronary angiography revealed a codominant system.
The LMCA
was angiographically normal. The LAD had a proximal 95%
thrombotic
lesion with slow flow. The LCX had a 80% lesion at the takeoff
of a
large OM1. The small nondominant RCA was angiographically
normal.
2. Hemodynamics post intervention showed elevated left sided
filling
pressure (PCWP mean 35 mm Hg with V waves to 46 mm Hg). There
was
moderate pulmonary arteriolar hypertension (PASP 55 mm Hg) in
the
setting of an elevated PCWP. The cardiac index was depressed at
1.9.
3. Patient was hemodynamically stable throughout the procedure,
but was
hypoxic to an O2 sat of 84% on a nonrebreather. He was given 40
mg IV
lasix and started on IV nitroglycerine and his sat improved to
100% with
a couple of deep breaths.
4. Successful placement of 3.0 x 18 mm Cypher drug-eluting stent
postdilated with a 3.5 mm balloon in the proximal LAD for this
acute ST
elevation myocardial infarction. Final angiography demonstrated
no
residual stenosis, no angiographically apparent dissection, and
normal
flow
.
[**2151-5-7**] Abd/Pelvis CT:
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage.
2. Patchy bilateral lower lobe opacities, worrisome for
aspiration. Atelectasis is a less likely possibility.
.
[**2151-5-7**] ECHO:
EF 40%
Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Anterior, distal
septal and apical hypokinesis to akinesis is present.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
.
[**2151-5-10**] CXR PA&L:
The heart is upper limits of normal in size. There is upper zone
vascular redistribution and worsening perihilar haziness.
Additionally, there is an asymmetrical opacity at the right apex
at the level of the first anterior right rib and right clavicle.
On the lateral view, there is increased opacity overlying the
lower thoracic spine, corresponding to the posterior basilar
segments of the lower lobes. Additionally, the lungs appear
overinflated with flattening of the hemidiaphragms.
.
[**2151-5-10**] Chest CT:
IMPRESSION:
1. Widespread pulmonary ground glass opacities, scattered foci
of consolidation and diffuse septal thickening. These findings
may represent pulmonary hemorrhage and/or pulmonary edema.
Infection is less likely.
2. Small pericardial effusion, slightly enlarged in comparison
to the previous film.
3. Bilateral small nonobstructing renal stones
.
[**2151-5-13**] C. Cath:
COMMENTS:
1.The lesion was predilated with a 2.5 X 12mm Voyager balloon,
stented
with a 3.5 X 18mm Cypher stent and post dilated with a 3.5 X
13mm High
sail balloon with lesion reduction from 80% to 0%. The final
angiogram
showed TIMI III flow with no residual stenosis, no dissection
and no
embolisation. The patient left the lab in a stable condition.
2. left ventriculogram was performed in [**Doctor Last Name **] projection with 36
ml of
contrast at 12ml/sec. The entire anterior wall and the apex,
except for
a small area in the anterior basal segment was akinetic. the EF
was
30-35%.
.
Bivalirudin 45 mg bolus, 110 mg hr drip post cath
.
[**2151-5-13**] ECG:
Sinus rhythm. Left atrial abnormality. Right bundle-branch block
with left
anterior fascicular block. Q waves in the inferior leads with
minimal
ST segment elevation and terminal T wave inversion consistent
with acute
evolving myocardial infarction. Diffuse non-specific ST-T wave
changes.
Compared to the previous tracing of [**2151-5-13**] there is probably no
significant change.
.
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-5-14**] 04:45AM 36.7* 361
[**2151-5-13**] 04:55AM 10.2 3.67* 11.9* 34.3* 93 32.4* 34.7 14.4
287
[**2151-5-6**] 08:08PM 13.2* 36.7* 207
[**2151-5-6**] 12:20PM 9.4 5.04 16.5 45.6 91 32.7* 36.1* 13.9
300
.
UreaN Creat Na K Cl HCO3 AnGap
[**2151-5-14**] 04:45AM 21* 1.2 4.3
[**2151-5-13**] 09:21PM 4.2
[**2151-5-13**] 04:55AM 121* 25* 1.2 141 4.2 104 27 14
.
CE:
CK(CPK)
[**2151-5-14**] 12:45PM 362
[**2151-5-14**] 04:45AM 348
[**2151-5-13**] 09:21PM 189
[**2151-5-11**] 08:50AM 355
[**2151-5-10**] 06:40AM 507
[**2151-5-8**] 04:58AM 1849
[**2151-5-7**] 07:24PM 2437
[**2151-5-7**] 04:00AM 4580
[**2151-5-6**] 08:08PM 6445
[**2151-5-6**] 12:20PM 135
.
CK-MB MB Indx cTropnT
[**2151-5-14**] 12:45PM 21* 5.8 2.85*
[**2151-5-14**] 04:45AM 24* 6.9*
[**2151-5-13**] 09:21PM 7
[**2151-5-11**] 08:50AM 4 5.59*
[**2151-5-10**] 06:40AM 5 5.94*
[**2151-5-8**] 04:58AM 21* 1.1 5.49*
[**2151-5-7**] 07:24PM 57* 2.3
[**2151-5-7**] 04:00AM 259* 5.7 14.32*
[**2151-5-6**] 08:08PM 496* 7.7* 23.07*
[**2151-5-6**] 12:20PM <0.01
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2151-5-7**] 04:00AM 121 901 40 3.0 63
.
HbA1c
[**2151-5-6**] 10:54PM 5.9
.
Brief Hospital Course:
Assessment/Plan:
53 year old male with p/w anterior wall STEMI s/p proximal LAD
stent and L-Cx stent.
.
#. CV - Ischemia - Pt p/w STEMI, found to have 90% LAD lesion
and 80% occlusion of circumflex. CE were cycled and peaked on
day of admission with peak CK 6445 and Tn-T 23.07. On day of
admission underwent stenting of proximal LAD. Pt was hypotensive
post cath and required IABP for 24hrs. IABP weaned off,
maintained own BP will low range 80s-90s SBP. He was not started
on pressors, his SBP responded to IVF. He was started on ASA,
Plavix, high dose statin immediately post cath. He also
underwent an Abdomen/Pelvic CT which ruled out an RP bleed. His
HCT had a small drop but did not require blood transfusions
throughout his hospitalization. In setting of hypotension
immediately following C. Cath, pt was not started on BB until
[**5-7**]. He was started on a low dose 12.5mg [**Hospital1 **] and tolerated well
with persistent SPB in 90s-low 100s. Pt underwent 2nd C. Cath on
[**5-13**] to revascularize Cx lesion without complications, he
recieved Bivalirudin 45 mg bolus, 110 mg hr drip. He did have
elevated MBI post 2nd cath-periprocedure NSTEMI. He was symptom
free. He remained CP free since his first cath, his CE trended
down and was discharge on ASA, Plavix, Statin, BB.
.
#. CV - Pump - Wedge of 30 in cath lab. Got lasix, and also ntg
gttp, weaned off when arrived to CCU. Low cardiac index of 1.9.
He had no evidence of cardiogenic shock, perfusing well with
good urine output. Hypotension most likely [**1-21**] hypovolemia, no
evidence of bleed. Pt had Abdominal/Pelvic CT which ruled out an
RP bleed. IVF given with good response in BP. ECHO with
moderately depressed LVsys function. EF of 40% with overall left
ventricular systolic function is moderately depressed. Anterior,
distal septal and apical hypokinesis to akinesis is present. He
was started on Hep gtt for anticoagulation while awaiting 2nd
cath, however [**1-21**] hemoptysis hep gtt was turned off. He was
subsequently diuresed with low dose of lasix 10mg daily for pulm
edema. He was maintained on 10mg lasix daily, however he was
autodiuresing making ~1L UOP daily. His lasix was d/c'd as BP
was somewhat tenuous while optimizing cardiac meds. On 2nd cath
ventriculography notable for entire anterior wall and the apex,
except for a small area in the anterior basal segment was
akinetic, with an EF of 30-35%. He was started on Lovenox and
transitioned to Coumadin. He was not started on an ACE-I since
his BP remained in the low 100s. He was scheduled to f/u with
Dr. [**Last Name (STitle) **] on Tuesday, [**5-18**] to have INR drawn. Will need to
start ACE-I as outpatient.
.
#. CV - Rhythm - Pt remained in NSR throughout his hospital
course.
.
#. Hemoptysis: Pt started to have hemoptysis on [**5-8**] after
having started hep gtt. Hep gtt was turned off for hemoptysis.
His Hct remained stable. High resolution Chest CT c/w dependent
ground glass opacities most likely pulmonary edema vs. pulm
hemorrhage. He was diuresed w/low dose of lasix daily with
improvement in O2 sats. He was r/o'd for TB with a negative PPD
formally read on [**5-12**] after 48hours, no sign of induration.
Induced sputum x3 was sent for AFB which were all negative. His
hemoptysis resolved. Will need f/u Chest CT as outpatient.
.
#. Hyperglycemia: Pt had persistent hyperglycemia requiring
Insulin. He had no known dx of DM, however, both [**Month/Year (2) **] are
diabetics. Formal [**Last Name (un) **] consult was obtained for new diagnosis
of DM and further management. His Hgb AIC was 5.9%. He was sent
home with a glucometer, started on glipizide [**Hospital1 **] and was set up
with [**Last Name (un) **] follow up with a Nurse educator as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
physician.
#. Hypothyroidism - continued on home dose of levoxyl.
.
#. Htn - on hyzaar as outpt. Had transient episode of
hypotension following C. Cath, without evidence of cardiogenic
shock or bleed. Abd/Pelvic CT r/o'd RP bleed. He remained
normotensive following STEMI. Started low dose BB for
cardioprotective effect, tolerated well, did not start ACE-I
during hospitalization as BP remained low 100s.
.
#. CODE: FULL
Medications on Admission:
Medications (home):
- lipitor 5 mg QD
- levoxyl 100 mcg QD
- hyzaar QD
.
Allergies:
- sulfa (rash as a child)
- bee stings-->anaphylaxis
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Glucometer Elite Classic Kit Sig: One (1) Miscell.
twice a day.
Disp:*1 kit* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 10 days.
Disp:*20 syringe* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
CAD
HTN
DM-diagnosed during this admission
Hypercholesterolemia
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed and keep all your
follow up appointments.
.
If you have chest pain, shortness of breath, palpitations, are
lighthead or have other worisome symptoms please call your
physician and go to the emergency room.
.
Please note you were started on the following medications:
-Toprol XL 50mg daily, Aspirin 325mg daily, Plavix 75mg daily,
Atorvastatin 80mg daily, Lovenox and Coumadin for your heart
-Your were started on glipizide for your diabetes
Followup Instructions:
You have an appointment with Cardiologist, Dr. [**Last Name (STitle) **], next
week:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2151-5-18**] 1:00
.
You have an appointment at [**Last Name (un) **] on [**5-25**] with a Nurse
Educator [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2pm and with Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 19862**]
at 10am on the same day at [**Last Name (un) **]. Please call [**Telephone/Fax (1) 2384**] if
you have any questions prior to your appointment.
.
You have a new PCP [**Name Initial (PRE) 648**]:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-5-31**]
2:00, you must call [**Telephone/Fax (1) 250**] to register prior to your
appointment to update your insurance information.
.
Please have your blood drawn in the [**Hospital Ward Name 23**] Center on the [**Location (un) **] on Wednesday, [**5-26**]. The lab is open from 7:30am-4pm,
if you have questions you may call [**Telephone/Fax (1) 250**].
Completed by:[**2151-5-15**]
ICD9 Codes: 4280, 9971, 4019, 2724, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4540
} | Medical Text: Admission Date: [**2151-5-22**] Discharge Date: [**2151-6-1**]
Date of Birth: [**2079-8-20**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: Briefly, this is a 71-year-old
male with a past medical history significant for coronary
artery disease and congestive heart failure who presented
with a 2-day history of abdominal pain and bloating. He had
been having nausea but denied any vomiting and was passing
flatus and had a hard bowel movement earlier that day. He
denied any fevers, chills, chest pain, or shortness of breath
and was having normal urine noting no darkness and no light
colored stools.
PAST MEDICAL HISTORY: (The patient's past medical history is
significant for)
1. Coronary artery disease; status post myocardial
infarction and status post coronary artery bypass graft in
[**2140**].
2. Congestive heart failure.
3. Atrial fibrillation; status post ablation.
4. Gout.
5. Severe psoriasis.
6. Arthritis.
7. Benign prostatic hypertrophy.
8. Hypertension.
9. High cholesterol.
PAST SURGICAL HISTORY: (Past surgical history is significant
for)
1. Coronary artery bypass graft.
2. Removal of skin tags.
MEDICATIONS ON ADMISSION: (The patient's medications
included)
1. Lasix 60 mg p.o. twice per day.
2. Spironolactone 25 mg p.o. once per day.
3. Atenolol 100 mg p.o. once per day.
4. Lipitor 20 mg p.o. once per day.
5. Folate.
6. Flomax 0.4 mg p.o. once per day.
7. Proscar 5 mg p.o. once per day.
8. Allopurinol 200 mg p.o. q.h.s.
9. Methotrexate 5 p.o. every week and then 2.5 p.o. every
day.
10. Coumadin 5 mg p.o. once per day.
11. Aspirin 325 mg p.o. once per day.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient was afebrile, temperature was 100.6, and
his other vital signs were stable. He was alert and oriented
and in no acute distress. His sclerae were anicteric. His
lungs were clear. His heart was regular. His abdomen was
soft, obese, distended, tympanitic, and tender in the right
upper quadrant with no guarding and no rebound. Rectal was
guaiac-negative with normal tone. Extremities were warm and
well perfused with no edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 21, his hematocrit was
34.2, and his platelet count was 238. His chemistries were
within normal limits except for a creatinine of 1.3. His
coagulations revealed INR was 3.5. His ALT and AST were 11
and 19; respectively. His alkaline phosphatase was 73. His
total bilirubin was slightly elevated at 1.5. His amylase
was 52. His lipase was 17.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was done in the
Emergency Department which showed mild pulmonary edema;
consistent with early congestive heart failure.
A KUB showed no dilated loops and no evidence of obstruction.
Computed tomography showed acute cholecystitis with a large
distended gallbladder with thickened wall and pericholecystic
fluid and inflammation with a low attenuation lesion in the
left lobe of the liver; consistent with a phlegmon.
HOSPITAL COURSE: The patient was admitted to the hospital
and made nothing by mouth. He was given intravenous fluids
and antibiotics. However, he did not improve on hospital day
one, and it was decided that the patient would need a
cholecystostomy tube placement. The patient had immediate
emergent reversal of his INR with fresh frozen plasma. He
was given 8 units of fresh frozen plasma to correct his INR;
however, his INR remained continued elevated to 1.9.
Therefore, an Interventional Radiology cholecystostomy tube
placement was unable to be performed. Therefore, the patient
was taken to the operating room on [**2151-5-22**] where an
open cholecystostomy tube was performed. Please see the
Operative Report for further details.
The patient was transferred to the Intensive Care Unit
postoperatively for fluid resuscitation and close monitoring
due to his heart. Cardiology was consulted prior to the
operation for a preoperative evaluation. They felt that
because of the emergent nature of the operation to go ahead
with the procedure and also felt that there was no clear
indication for the patient to be on Coumadin. Therefore, it
was stopped.
The patient did well postoperatively. However, he continued
to require fluid for resuscitation. Because of his septic
physiology, the patient was started on broad-spectrum
antibiotics including penicillin, levofloxacin, and Flagyl
and was continued on that for a total of a 21-day course.
The patient continued to improve in the Intensive Care Unit
and was slowly getting better. Therefore, it was decided the
patient could be transferred to the floor. Gentle diuresis
was begun due to the patient's tenuous cardiac status. He
tolerated this well. The patient was started on total
parenteral nutrition postoperatively due to the suspected
long period of nothing by mouth status. The patient was also
kept with an nasogastric tube in place for the first three
postoperative days due to the extreme amount of inflammation
in his abdomen.
Physical Therapy was consulted for ambulation and for
strength training. He did well and it was felt that the
patient could to home when medically stable.
He slowly improved throughout his hospital course and after
beginning to pass flatus his nasogastric tube was removed and
his diet was advanced. The patient did well with clears and
was taking a decent amount of a clear liquid diet; therefore,
his total parenteral nutrition was stopped, and his central
line was removed and cultured. The patient's white blood
cell count was rising at that time but started to return to
normal after removal of the central line. He had a repeat
computed tomography scan to re-evaluate the abdominal cavity;
specifically the hepatic low attenuation lesion which looked
unchanged from the prior computed tomography scan, and the
inflammation had reduced. Therefore, it was decided that the
patient could follow up for further planned operative removal
of his gallbladder at a future time.
The patient continued to do well, and his diet was advanced.
He was tolerating a soft/solid diet postoperatively, and he
continued to do well on that.
On [**2151-5-30**], the patient was unable to void with his
Foley catheter removed. Therefore, a new Foley catheter was
placed. The patient had the Foley catheter removed again,
and given his doses of Flomax Physical Therapy felt that he
was doing well and comfortable on his ambulation. Therefore,
it was decided that the patient could be discharged home.
DISCHARGE DIAGNOSES:
1. Gangrenous cholecystitis.
2. Status post open cholecystostomy tube.
3. Coronary artery disease; status post myocardial
infarction and status post coronary artery bypass graft.
4. Congestive heart failure.
5. Atrial fibrillation; status post ablation.
6. Gout.
7. Psoriasis.
8. Arthritis.
9. Benign prostatic hypertrophy.
10. Hypertension.
11. High cholesterol.
MEDICATIONS ON DISCHARGE: (Discharge medications were)
1. Lasix 60 mg p.o. twice per day.
2. Spironolactone 25 mg p.o. once per day.
3. Atenolol 100 mg p.o. once per day.
4. Lipitor 20 mg p.o. once per day.
5. Folate.
6. Flomax 0.4 mg p.o. once per day.
7. Proscar 5 mg p.o. once per day.
8. Allopurinol 200 mg p.o. q.h.s.
9. Methotrexate 5 p.o. every week and then 2.5 p.o. every
day.
10. Coumadin (discontinue).
11. Aspirin 325 mg p.o. once per day.
12. Percocet one to two tablets p.o. q.4h. as needed (for
pain).
13. Colace 100 mg p.o. twice per day (as a stool softener).
14. Levofloxacin 750 mg p.o. once per day (for 11 further
days for a planned completion of a 21-day course).
15. Flagyl 500 mg p.o. three times per day (for 11 further
days).
16. Penicillin 500 mg p.o. four times per day (for 11
further days to complete a 21-day course).
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: He was given [**Hospital6 3429**] services for drain care and management of
his open cholecystostomy tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Dictator Info 98693**]
MEDQUIST36
D: [**2151-5-31**] 13:28
T: [**2151-5-31**] 15:36
JOB#: [**Job Number **]
ICD9 Codes: 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4541
} | Medical Text: Unit No: [**Numeric Identifier 72885**]
Admission Date: [**2163-7-23**]
Discharge Date: [**2163-9-16**]
Date of Birth: [**2163-7-23**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname **] 3 was the 1240 gram product of a 30
and [**3-23**] week di-tri triplet Clomid gestation with EDC [**2163-9-29**] born to a 31-year-old, G-1, P-0 mom with prenatal
screens, blood type O negative, antibody negative, RPR non-
reactive, rubella immune and GBS unknown. The mom was treated
with RhoGAM on [**7-4**]. She was treated with betamethasone at
27 weeks. The pregnancy was complicated by preterm labor.
This infant was born via C-section with Apgar score of 6 at 1
minute and 8 at 5 minutes.
SOCIAL HISTORY: The mom is a teacher and married to the
father of the baby whose name is [**Name (NI) **].
FAMILY HISTORY: Otherwise was noncontributory.
REVIEW OF SYSTEMS: Unavailable.
PHYSICAL EXAMINATION ON ADMISSION:
Exam on admission:
Weight 1240 grams (50th percentile), HC 28 cm (50th percentile),
length 38 cm (25th percentile)
T 97.5, HR 158, RR 34, BP 78/42 (56) , O2 sat 86%
HEENT: Anterior fontanelle was open and flat. Palate was intact.
Red reflex present bilaterally.
Neck: supple
Skin: Pink, intact, bruising noted on the lower right leg. Chest:
Shallow respirations.
Cardiovascular: Regular rate and rhythm. No
murmur.
Abdomen: Soft with active bowel sounds. No masses or
distention.
Extremities: Warm, well perfused. Brisk cap
refill. Hips were stable. Clavicles intact. Spine was midline
with no dimples.
Neuro: Moved all extremities.
PHYSICAL EXAMINATION ON DISCHARGE: Weight 2500 g,
length 43 cm, HC 31.75 cm
HOSPITAL COURSE BY SYSTEMS:
Respiratory: Initially the baby was intubated and got Surfactant
x 1. She was quickly weaned to CPAP on day of life 1 which she
stayed on until day of life 3 when she came off the CPAP and had
been on room air since that time. She had apnea of prematurity
which has resolved.
Cardiovascular: The baby's blood pressures were stable at
birth. She did have a murmur which was worked up with an echo.
The echo showed no PDA, no significant valvular dysfunction,
qualitatively good biventricular function and no pericardial
effusion. She did have a small PFO with bidirectional
shunting. Otherwise she has been stable and currently has no
murmur.
Fluids/electrolytes/nutrition: The baby was started NPO on IV
fluids. She did get TPN for a short amount of time and was
started on breast milk feeds which she advanced as tolerated.
She currently is on ad lib feeds of Enfamil 24 and
tolerating them well without aspirates or spits.
GI: The baby had hyperbilirubinemia diagnosed on day of life
1 and received phototherapy for several days. The
phototherapy was discontinued on day of life 7 and she did
well since that time. No current issues.
Hematology: The baby's blood type is O negative. She never
received a transfusion. She was started on iron and vitamin E
on day of life 14. The vitamin E was discontinued on day of
life 41 and she continues on iron supplementation at a dose of 2
mg/kg/day.
Infectious disease: The baby had a rule out sepsis workup at
birth with amp and gent for 48 hours. No current issues.
Neurology: The baby had 2 head ultrasounds both normal, the
last one being on [**8-23**].
Sensory/audiology: Hearing screening was performed with
automated auditory brain stem responses which the baby passed
on [**9-11**].
Ophthalmology: The baby had 2 ophthalmologic exams. The eyes
were examined most recently on [**9-5**] revealed immaturity of the
retinal vessels but no ROP as yet. A follow will be
done in 2 weeks from discharge.
CONDITION ON DISCHARGE: Stable and excellent.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **], [**Hospital 1426**]
Pediatrics, phone # ([**Telephone/Fax (1) 56268**]
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue Enfamil 24K cals ad
lib.
2. Medications: The baby was to continue on iron sulfate 2
mg/kg/day.
3. Iron and vitamin D supplementation: Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants that
predominantly breast milk should receive vitamin D
supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening: The baby had a car seat test
done on [**9-11**] and passed.
5. State newborn screening status: The baby had multiple
state screens which have all been within normal limits.
6. Immunizations received: The baby received hepatitis B
vaccination on [**8-22**].
7. Immunizations recommended: 1.) Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria: 1. Born
at less than 32 weeks; 2. Born between 32 and 35 weeks
with 2 of the following: day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings; 3. Chronic lung
disease; or 4. Hemodynamically significant congenital
heart disease. 2.) Influenza immunization is recommended
annually in the fall for all infants once the baby
reaches 6 months of age, before this age and for the
first 24 months of the child's life. Immunization against
influenza is recommended for household contact and out of
home care givers. 3.) This infant has not received the
rotavirus vaccine. The American Academy of Pediatrics
recommends initial vaccination of preterm infants at or
following discharge from the hospital if they are
clinically stable and at least 6 weeks but fewer than 12
weeks of age.
8. Follow-up appointment schedule recommended:
1. Baby girl [**Known lastname **] has pediatric followup scheduled on
Monday with her primary care physician.
2. Ophthalmology followup is scheduled for [**10-3**].
DISCHARGE DIAGNOSIS:
1. Prematurity 30 [**3-23**].
2. Triplet pregnancy.
3. Respiratory distress syndrome, resolved
4. Rule out sepsis, resolved
5. Hyperbilirubinemia, resolved
6. Sepsis evaluation, complete
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2163-9-16**] 08:45:45
T: [**2163-9-16**] 09:53:57
Job#: [**Job Number 72886**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4542
} | Medical Text: Admission Date: [**2105-3-9**] Discharge Date: [**2105-3-11**]
Date of Birth: [**2042-9-3**] Sex: M
Service: PSYCHIATRY
Allergies:
Aspirin / Seroquel
Attending:[**First Name3 (LF) 2448**]
Chief Complaint:
Patient transferred from the Neurology Service for further Tx of
catatonia.
Major Surgical or Invasive Procedure:
s/p ECT 1 on [**2105-3-11**]
History of Present Illness:
Mr. [**Known lastname 106945**] is a 62 year old male with BPAD and Parkinson's
disease who initially presented to the [**Hospital1 18**] ED on [**1-14**] with
change in
mental status. In the ED, patient had negative serum and urine
tox, U/A (-) for UTI, no leukocytosis, negative head CT and
unremarkable EKG. He was admitted to the medicine floor and
psychiatry consulted to evaluate for psychosis as patient is
extremely disorganized and appears to be hallucinating.
On [**1-24**], patient was noted to have a question of an atypical
dystonic rxn to quetiapine. He received IM benadryl, and sx's
resolved. On [**1-29**], patient was transferred to [**Hospital1 **] 4 (until
[**2-4**]). His
quetiapine was titrated up to 75mg PO BID. On [**1-30**], he had an
LFT
bump and CK elevation. Quetiapine was stopped out of concern
for
rhabdomyolysis. On [**2-4**], patient had an episode of
unresponsiveness x 30 minutes. As such he was transferred to the
Neurology service for further management. Per the Neurology
service, he had no
further episodes of unresponsivness.
During the [**Hospital 228**] hospital course, he was found to
have extremely rapid, pressured speech, echolalia, and
disorganized speech and thought process. A UA and CXR
were negative for infectious etiology of his clinical picture.
An MRI/MRA of the head showed no evidence of acute infarct, and
a normal Circle of [**Location (un) 431**] on MRA. The patient was seen by the
psychiatry consult service who felt his clinical picture
appeared to be consistent with an excited catatonia. He was
started on standing Ativan for the excited catatonia but there
was little improvement in the patient's pressured speech,
echolalia, disorganized thought and speech, and confusional
symptoms. Emergency guardianship was pursued so that
the patient could obtain ECT treatment.
He was transferred to [**Hospital1 **]-4 on [**2105-3-9**] for further
treatment and evaluation for ECT>
Past Medical History:
1. HCV- last VL 8,590,000 on [**9-22**], followed by Dr. [**Last Name (STitle) **], on
colchicine week 146 in the COPILOT study, last biopsy [**8-26**] with
gr 2 inflammation and stage 4 cirrhosis, gr I/II varices
2. Type II diabetes, last HgA1C 8.7 [**12/2104**]
3. Parkinson's disease, followed by Dr. [**Last Name (STitle) **]
4. Post-traumatic stress disorder, followed by Dr. [**Last Name (STitle) 3704**]
5. Last colonoscopy [**7-25**] with adenomatous rectal polyp and
sigmoid diverticulosis
6. s/p cholecystectomy
7. s/p R inguinal hernia repair ([**2097**])
8. Bipolar affective disorder
Social History:
Patient states that he was "born and raised and breast fed too"
in [**Location (un) 10684**], GA. He has 2 brothers. Is a veteran. Married and
lives with his wife in [**Location (un) 686**].
Family History:
Father died of unknown cause at age [**Age over 90 **], brother died in 60s of
alcoholic liver disease, mother still alive, no cancer in the
family
Physical Exam:
Elderly, thin, African-American male, sitting in bed
comfortably awake. Alert and immediately responsive to voice.
Speech with slightly increased rate, but improved from my
previous evaluation several weeks ago. Motor: no PMA. No
echopraxia. increased tone in bilateral upper extremities Mood:
"I am feeling good" Affect: restricted, euthymic. TC: He is
unable to articulate his own thought content. continues to have
echolalia and perseveration. appears more engaged in
conversation
than previously. Orientation : "9th and 10th, [**2076**]....with my
mother, son, and baby boys" Attention: unable to state days of
the week backwards: "Mon, Tues, Wed, Thurs, Fri, Sat, sun" and
then repeats DOW forwards continuously and rapidly until asked
to
stop. President: "[**First Name8 (NamePattern2) 4049**] [**Last Name (NamePattern1) **] Epsilon [**Doctor Last Name **]"
Registration [**2-21**], recall 0/3 "[**Last Name (LF) 2450**], [**First Name3 (LF) **], French"
Pertinent Results:
[**2105-3-10**] 04:40PM BLOOD WBC-4.1 RBC-4.26* Hgb-13.5* Hct-39.8*
MCV-93 MCH-31.7 MCHC-33.9 RDW-13.6 Plt Ct-153
[**2105-3-10**] 04:40PM BLOOD Neuts-45.1* Lymphs-46.2* Monos-5.3
Eos-3.3 Baso-0.3
[**2105-3-10**] 04:40PM BLOOD Plt Ct-153
[**2105-3-10**] 04:40PM BLOOD Glucose-321* UreaN-18 Creat-1.2 Na-135
K-4.3 Cl-98 HCO3-31 AnGap-10
[**2105-3-10**] 04:40PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1
Brief Hospital Course:
This is a 62 year old male with BPAD and Parkinson's disease
admitted to [**Hospital1 **]-4 with diagnosis of excited catatonia.
1. Legal: Pt. initially admitted to the unit on a Section 12.
[**Name (NI) **] wife (legal guardian) signed a Conditional Voluntary
form one day after admission.
2. Psych: Patient admitted to the psychiatric unit from the
Neurology Service on [**2105-3-9**]. Patient poorly communicative,
would respond in [**12-23**] word sentences. He was compliant with all
medications. After medical clearance was obtained (previous
clearance was > 30 days old), patient underwent ECT # 1 without
any complications. He remained in his room most of the time, did
not participate in group or individual therapy.
3. Medical: On [**2105-3-11**], patient underwent ECT as planned, with
peri-procedure brevital and succinylcholine, without any adverse
events. He appeared to recover from the procedure without
complications.
He was noted to be shaking at 1PM (thought to be from
Parkinson's), was given his Ativan and Sinemet. At 2:30PM, he
was found to be rigoring, with T=103 in resp. distress with RR
in 40s and tachy 138 and O2 sats in 60s. A medical trigger was
called and patient transferred to the MICU..
4. Psychosocial: [**Name (NI) **] wife was [**Name (NI) 653**], who signed
necessary paperwork for ECT. No family meetings were held during
this short admission.
Medications on Admission:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
10. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical ASDIR (AS
DIRECTED) as needed for seborrheic dermatitis.
11. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING
SCALE UNITS Injection ASDIR (AS DIRECTED).
Discharge Medications:
Patient transferred emergently to the ICU, on same medications
as on admission.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Axis I - catatonia
Axis II - deferred
Axis III - sepsis
Discharge Condition:
medically unstable
Discharge Instructions:
transfer stat to MICU 7
Followup Instructions:
transfer to MICU 7
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2461**]
Completed by:[**2105-3-12**]
ICD9 Codes: 5070, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4543
} | Medical Text: Admission Date: [**2110-6-4**] Discharge Date: [**2110-6-12**]
Date of Birth: [**2110-6-3**] Sex: F
Service: NB
ID: Baby Girl ([**Known lastname **]) [**Known lastname 64032**] is a 9 day old term infant with
Trisomy 21 and resolving primary pulmonary hypertension who is
being transferred from the [**Hospital1 18**] NICU to the [**Hospital3 **]
SCN.
HISTORY: Baby Girl [**Known lastname 64032**] is a former 3.545 product of a 41
week gestation pregnancy born to a 36 year-old gravida II,
para II-I woman whose pregnancy was apparently complicated
only by an elevated triple screen. Amnio declined. Antenatal
ultrasound said to be normal but full report not available at
time of delivery.
Prenatal screens complete and unremarkable. B negative,
antibody negative, hepatitis B surface negative, RPR
nonreactive, rubella immune, GBS negative. No sepsis risk
factors noted.
Delivery by cesarean section on [**6-3**] at approximately 6
P.M. Did well at delivery. Apgars of 7 at one minute, 8 at
five minutes. Neonatal Intensive Care Unit team called at
about 10 minutes of age for grunting, flaring and retracting.
This quickly resolved. On examination at that time normal
cardiac examination and lung examinations. Tone slightly
decreased throughout. Nipples not hypoplastic. No brush
filled spots. Occiput not flattened. Subsequently went to
newborn nursery. At approximately 6 hours of age the patient
was noted to have cyanotic episodes. Seen by the Neonatal
Intensive Care Unit team and was desaturating on room.
Brought to the Newborn Intensive Care Unit with blow-by O2
and saturations in the high 70s noted. No respiratory
distress noted. Placed on continuous positive airway pressure
with 100% O2 and had a slow increase from the 80s to the 90s.
EXAMINATION: Pink active infant with vigorous cry. Skin
without lesions. Head, eyes, ears, nose and throat with thin
upper lip, somewhat prominent tongue. Eyes with slightly
downward slant. Occiput normal. Cor normal, S1, S2 without
murmur. Precordium normally active. Four extremity blood
pressure without gradient. Lungs clear with fair aeration.
Abdomen soft, nondistended, no masses. Toes normally spaced.
No simian creases. Axial tone slightly decreased.
Appendicular tone normal. Neurologic otherwise normal. Spine
intact. Hips normal. Anus patent.
Initial post ductal pO2 difficult to obtain; pre-ductal arterial
puncture on 100% O2 showed pH of 7.24, CO2 of 46, pO2 of 37 and
repeat arterial blood gas from umbilical arterial line showed pH
of 7.33, CO2 38, pO2 69, 21-5. Chest x-ray shows relatively clear
lung fields, heart size slightly increased, RA prominent, TBF
normal to slightly decreased. Electrocardiogram normal for age.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: Baby was placed on continuous positive airway
pressure of 6 cm requiring 85 to 100% O2. ECHO revealed
pulmonary hypertension. Oxygen therapy was continued, and infant
exhibited gradual improvement. She initially remained on CPAP
and then was transitioned to oxygen [**Doctor Last Name **] by day of life 2. Oxygen
requirement gradually weaned from 100% to 30%, and she then
transitioned to a nasal cannula O2 on day of life 3, [**12-17**] liter
100% O2 with saturations greater than 98. Arterial gas on nasal
cannula O2 pH 7.36, pCO2 of 40, pO2 104, 24-2. Nasal cannula
requirement weaned over next several days, but then plateaued at
25-50 cc. By the time of transfer, the infant has had several
period in room air, but is mostly in nasal cannula oxygen, 25 cc.
Bilateral breath sounds are clear and equal. Baseline respiratory
rate 30s to 50s. No apnea has been noted. Of note, initial CXR
did suggest a small left pneumothorax, which resolved on
subsequent films.
CARDIAC: On [**6-4**] echocardiogram was performed because of
concern for cardiac anomaly. This showed right ventricular
hypertension, right ventricular dilatation with moderate
right ventricular dysfunction, normal left ventricular size
and systolic flow, patent foramen ovale, bidirectional low
velocity flow across the patent ductus arteriosus consistent
with systemic pulmonary arterial pressure. Overall findings
were consistent with primary pulmonary hypertension.
Baby has had no murmur. Baseline heart rate 90 to 120s.
Recent blood pressure 80/53 with the mean in the 60s. Baby
did not require any pressor support and is currently
cardiovascularly stable. Of note, on initial admission did
reveal one normal saline bolus for poor perfusion.
FLUID, ELECTROLYTES AND NUTRITION: The patient initially had
breast-fed and newborn nursery was made n.p.o. upon admission
to the Neonatal Intensive Care Unit, was started on
maintenance IV fluid at 60 ml per kilo per day of D10W and
ultimately transitioned to receive some parenteral nutrition
intravenously. She had a double lumen UVC line inserted and
an umbilical arterial line to monitor blood pressures. Her
umbilical arterial line was discontinued on day of life 2 as
her respiratory and cardiovascular condition stabilized. Her
double lumen UVC line was removed on day of life 3. Enteral
feedings were introduced on day of life 3. She advanced to
full enteral feedings of breast milk or Enfamil 20 ad lib
without incident. She is currently taking in greater than 120
ml per kilo per day. She is voiding and stooling, has had no
gastrointestinal issues.
Of note, she had a peripheral IV infiltrate in her right
hand. This has been followed by the plastic surgery team from
the [**Hospital3 1810**]. Digits are warm and well perfused.
The skin over the right dorsal hand has had areas of
sloughing. There has been some expected epidermolysis.
Plastic surgery anticipates there may be some full thickness
skin loss but from spontaneous activity appears to have
normal extension and flexion and a good strong grasp.
Currently xeroform and Telfa dressings are applied with dry
sterile dressing. There is no evidence of infection. The eschar
is servicing as a biological dressing for now and plan is for
Dr. [**Last Name (STitle) 5385**] to follow up with the family in one to two weeks
after discharge. Family has met with Dr. [**Last Name (STitle) 5385**] in his office
and his phone number si [**0-0-**].
Last electrolytes on [**6-6**]: Sodium 140, potassium 3.7,
chloride 106, CO2 was QNS'd. Previous electrolytes on [**6-5**]: 144, 3.1, 110, 26.
Admission birth weight 3545 grams, 7 pounds, 13 ounces,
admission length 19 inches or 48 cm. Admission head
circumference 34 cm. Discharge weight 3600 grams.
GASTROINTESTINAL: On day of life 1 there was some
abdominal distention noted. Initial KUB showed some suggestion of
pneumatosis, but subsequent films were within normal limits, and
exam normalized rapidly. Bilirubin on day of life 2: 2.0, 0.4,
1.9. No photo therapy has been indicated.
HEMATOLOGY: The baby has not required any blood products
during this admission. Initial admission hematocrit was 51.7.
INFECTIOUS DISEASE: On admission the baby had a sepsis
evaluation done. Had a white count of 13.1, 71 polys, 9
bands, 10 lymphs, 3 metas, platelet count of 219 and
hematocrit of 51.7. She was started on ampicillin and
gentamicin. Blood cultures remained negative. The baby was
improved at 48 hours and antibiotics were discontinued.
GENETICS: Because of subtle features consistent with trisomy-
21 chromosomes were sent and were positive for trisomy-21.
Parents were informed of this diagnosis on [**6-6**] and are
appropriately coping with the diagnosis. They have been
referred to the Downs Program at the [**Hospital3 1810**].
They have declined contact at this time and plan is for
[**Name (NI) **] [**Last Name (NamePattern1) **] to contact the family some time next week at
their home. The telephone number of the Downs Program is [**Telephone/Fax (1) 64033**].
Parents have also been working with the occupational
therapist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38698**]. She can be reached at [**Telephone/Fax (1) 41276**].
They will be followed by early intervention after discharge
and area aware that referral will occur prior to discharge.
NEUROLOGY: On examination baby is slightly hypotonic
consistent with trisomy-21.
SENSORY: Audiology screening has not been performed at time
of transfer. Ophthalmology: Eye examination has not been
performed.
PSYCHOSOCIAL: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] is the social worker who has been
working with this family. She can be reached by calling [**Telephone/Fax (1) 64034**] and having her paged if there are any additional
questions. She has given the family an application for SSI.
Parents are looking forward to transitioning closer to home
and celebrating the birth of [**Known lastname **].
Primary Pediatrician: Dr. [**Last Name (STitle) 64035**], [**Location 9583**], [**Telephone/Fax (1) 64036**]. She is aware of [**Known lastname 46036**] birth.
CARE RECOMMENDATIONS: Continue ad lib feedings of breast
milk or Enfamil 20 with iron ad lib. Medications: Current
medications include Tri-Vi-[**Male First Name (un) **] 1 ml p.o. q.d. Car seat
screening has not been performed. State newborn screening:
Initial screen on [**6-6**] showed an elevated TSH (24) with a
repeat being sent on [**6-12**].
IMMUNIZATIONS RECEIVED: None to date with plan to discuss
hepatitis B vaccination prior to discharge.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school age siblings, or 3) with chronic lung disease.
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 care givers.
Follow up appointments with primary care pediatrician per
routine, Dr. [**Last Name (STitle) 64035**], [**Location 9583**], [**Telephone/Fax (1) 43528**]. With the
Downs Program at [**Hospital3 1810**] [**Telephone/Fax (1) 64037**]. With Dr.
[**Last Name (STitle) 5385**], plastic surgery at [**Hospital3 1810**] in one to two
weeks, [**0-0-**].
DISCHARGE DIAGNOSES:
1. Term infant with trisomy-21.
2. Status post respiratory distress and persistent pulmonary
hypertension.
3. Status post rule out cardiac disease.
4. Status post rule out sepsis with antibiotics.
5. Probable small pneumothorax, resolved.
6. Right hand infiltrate.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2110-6-12**] 11:42:37
T: [**2110-6-12**] 13:26:50
Job#: [**Job Number 64038**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4544
} | Medical Text: Admission Date: [**2108-8-5**] Discharge Date: [**2108-8-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male s/p unwitnessed fall at home; found at bottom of
stairs by family member; down for unknown period of time.
Patient unable to recall events surrounding the fall.
Past Medical History:
Atonic Bladder
Hypertension
Dementia
+VDRL
Social History:
Retired truck driverLives alone in 2 story building; has VNA to
change suprapubic tube. HHA to assist with ADL's. Has one son
who visits on weekends.
Family History:
Noncontributory
Physical Exam:
VS upon arrival to trauma bay:
T 96.4 BP 127/72 HR 89 RR 20 room air Sats 98%
Gen: NAD, alert
HEENT: PERRL, EOMI
Chest: CTA bilat, no crepitus
Cor: RRR
Abd: soft, NT, ND. Suprapubic catheter in place
Back: diffusely tender spine, no stepoffs, no deformities
Rectum: Normal tone, guaiac negative
Extr: no edema, DP 2+ bilat, FROM x4
Pertinent Results:
[**2108-8-5**] 04:00PM cTropnT-0.05*
[**2108-8-5**] 04:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2108-8-5**] 04:00PM TSH-1.5
[**2108-8-5**] 04:00PM PT-13.6* PTT-29.2 INR(PT)-1.2
[**2108-8-5**] 08:18AM GLUCOSE-155* LACTATE-2.7* NA+-137 K+-4.8
CL--101 TCO2-24
[**2108-8-5**] 08:18AM HGB-14.6 calcHCT-44
[**2108-8-5**] 08:10AM ALT(SGPT)-33 AST(SGOT)-54* CK(CPK)-371* ALK
PHOS-85 AMYLASE-71 TOT BILI-0.8
[**2108-8-5**] 08:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-8-5**] 08:10AM WBC-14.8* RBC-4.98 HGB-14.9 HCT-42.9 MCV-86
MCH-30.0 MCHC-34.8 RDW-13.8
[**2108-8-5**] 08:10AM PLT COUNT-230
CTA NECK W&W/OC & RECONS [**2108-8-7**] 11:03 AM
CTA NECK W&W/OC & RECONS; CT 150CC NONIONIC CONTRAST
Reason: r/o vascular injury (CTA neck only)
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **]yo M s/p fall with dens fx, change in MS
REASON FOR THIS EXAMINATION:
r/o vascular injury (CTA neck only)
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall with dens fracture, change in
mental status. Rule out vascular injury. CTA neck only.
TECHNIQUE: CTA neck with multiplanar reconstructions,
three-dimensional reconstructions.
FINDINGS: There is a plaque with ulceration at the origin of the
left internal carotid artery. The residual lumen at site of the
stenosis is approximately 3 mm. There is also an ulcerative
plaque seen in the right internal carotid artery at a similar
level without significant stenosis. The remainder of the
visualized vessels is within normal limits without stenosis,
extravasation or aneurysm formation. Calcified plaques are noted
in the aortic arch. The visualized soft tissue structures appear
unremarkable without pathologic enhancement. The visualized lung
portions are unremarkable without pneumo- or hemothorax. Mucosal
thickening is noted in the sphenoid and bilateral maxillary
sinuses without air fluid levels.
IMPRESSION: Plaque with ulceration at the proximal left internal
carotid artery with a residual lumen of 3 mm. This represents a
50% stenosis. Ulcerated plaque without significant stenosis in
the right proximal internal carotid artery. No active
extravasation.
PRELIMINARY REPORT: No active extravasation. Proximal right ICA
may contain a web as there is very focal narrowing. Proximal
left ICA has an area that may represent an ulcerative plaque or
early dissection. [**First Name8 (NamePattern2) **] [**Doctor Last Name 18954**] MDMBA
CT HEAD W/O CONTRAST [**2108-8-7**] 11:02 AM
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with agitation, s/p fall with dens fx
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CT SCAN OF THE BRAIN, [**2108-8-7**]
INDICATION: [**Age over 90 **]-year-old man with agitation after a fall and dens
fracture, rule out intracranial hemorrhage.
TECHNIQUE: Axial non-contrast CT scans of the brain were
obtained. Comparison is made to an MRI of the brain from
[**8-5**] and a CT scan of the brain from [**2108-8-5**].
FINDINGS:
There is no change in the appearance of the brain, compared to
previous studies. No acute hemorrhage is evident. There are no
abnormal extra-axial collections. There is no intracranial mass
effect or shift of structures. The ventricles are not dilated.
An old right cerebellar infarction and areas of white matter
hypodensity, likely chronic microvascular infarction, are noted
and unchanged.
There is mucosal thickening in the ethmoid and frontal sinuses
and a small amount of fluid in the right sphenoid sinus. The
mastoids are aerated.
IMPRESSION: Stable appearance of the brain, compared to recent
previous studies. No evidence of acute intracranial hemorrhage.
KNEE (AP, LAT & OBLIQUE) LEFT [**2108-8-8**] 1:38 PM
KNEE (AP, LAT & OBLIQUE) LEFT
Reason: r/o fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man s/p fall
REASON FOR THIS EXAMINATION:
r/o fx
INDICATION: [**Age over 90 **]-year-old man status post fall. Evaluate for
fracture.
THREE VIEWS OF THE LEFT KNEE:
There is a fracture of the inferior patella transfixed by a
cerclage wire. The fracture margins appear indistinct and old.
There is a joint effusion, with an equivocal fat-fluid level.
The oblique view demonstrates a vertical linear lucency with
could represent an more acute non- displaced fracture. If the
hardware in the patella was not placed in the past several weeks
or months, then that lucency does indeed represent a new non-
displaced patellar fracture. No other acute fracture is
identified about the knee.
IMPRESSION:
Old patellar fracture transfixed by cerclage wire. Probable new
nondisplaced patellar fracture.
ADDENDUM [**2108-8-10**] - Please note that the original house officer
dictation did not reflect the presence of the joint effusion or
suspected acute fracture. This change in [**Location (un) 1131**] was discussed
with [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**] on [**2108-8-10**] at 2:45 pm, who confirms that the old
patellar fracture was remote.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic Spine was
immediately consulted because of his cervical spine injuries.
Recommended non-surgical intervention with cervical collar for
2-3 months. Neurosurgery consulted for patient's cervical
fracture as well, recommendations for further radiologic imaging
to evaluate for any vertebral artery dissection and monitoring
neurological status. Vascular surgery consulted for likely
dissection of left ICA, recommendations for ASA for
anticoagulation; no Heparin given history falls; and re imaging
if patient develops signs and symptoms. Geriatrics consulted
given patient's mechanism of injury; delirium identified and
recommendations made re: treating his delirium; Olanzapine
started; bone densitometry while in rehab to screen for
osteoporosis and initiating Calcium with Vit D. Speech and
Swallow consulted for his dysphagia; bedside swallow study
performed. Recommendations for nectar thick liquids and ground
diet. Physical therapy consulted due to patient's decreased
functional mobility and falls; recommendations for rehab stay
after discharge from hospital. Patient sustained a mechanical
fall during his hospitalization; a head CT scan and films of his
left knee were obtained; no intracranial hemorrhage identified.
Knee films revealed questionable non displaced patellar
fracture, Orthopedics was consulted and recommended a knee
immobilizer and and follow up in 3 weeks.
Medications on Admission:
Aricept
Toprol
Trazadone
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Fall
C2 dens fracture
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your cervical collar for next [**9-12**]
weeks.
Follow up with Orthopedic Spine & Vascular Surgery after your
discharge.
Followup Instructions:
Follow up with Orthopedic Spine in [**3-7**] weeks after discharge,
call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up with Vascular Surgery, Dr. [**Last Name (STitle) **] in 4 weeks,
call [**Telephone/Fax (1) 2625**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4545
} | Medical Text: Admission Date: [**2171-10-15**] Discharge Date: [**2171-11-14**]
Date of Birth: [**2109-12-29**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Zosyn
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year old male with severe CAD, unrevascularizable, s/p
cardiac arrest with anoxic brain injury [**5-/2171**], chornic
bronchitis, osteomyelitis, trached and peged, living in extended
care, admitted to the MICU after presenting to the ED with
respiratory distress. Was reportedyl in USOH when had episode of
hypoxia, fevers to 101 and tachycardia. Was placed on NRB and
sating 90-100% on transfer to ED.
.
In ED - was able to be weaned to trach mask with good
saturations nad no respiratory distress. Got 1gm Vancomycin and
tylenol. Was per call-in reportedly was on Zosyn for pseudomonas
colonization. When on floor, BP noted to be 70s systolic,
responded well to IV fluid bolus.
.
Of note: recently admitted [**8-14**], discharge [**8-21**] for fevers,
tachycardia, tachypnea. Was discharged on a 5 week course of
vancomycin for osteo that was newly diagnosed on MRI imaging of
the hip, located @ ischial tuberosity and coccyx. - no biopsy
or debrediment performed.
Past Medical History:
# CAD - 3VD s/p cardiac arrest w/anoxic brain injury as above.
Arrest was in setting of left hip fracture and repair.
has 3VD not revascularizable
# ischemic cardiomyopathy (EF 25%)
# Osteomyelitis - recently diagnosed ([**7-/2171**]) during above
admission.
# Sensorimotor demyelinating polyneuropathy, confirmed by EMG
per the pt's brother. Pt. has resultant paraparesis
# suspected colonization of airway with pseudomonas (pan
sensative)
# UTIs
# chronic renal insufficiency, known horseshoe kidney
# chronic sacral and ischial decubitus ulcers
# H/O chronic indwelling foley
# h/o afib (currently not anticoagulated, not rate controlled,
and not in afib
# Hyperlipoidemia
# h/o AAA
# Schizophrenia
# prior strokes seen on CT head
# h/o dementia
Social History:
The pt. is a resident of a skilled nursing facility. There is no
history of alcohol use. The pt. quit smoking tobacco 2 years ago
after approximately 20 years of use. He is a former electrical
engineer. His Brother [**Name (NI) 11312**] [**Name (NI) 14714**] is actively involved in
his care.
Family History:
NC
Physical Exam:
Admit exam:
98.5 109 109/70 22 99-100%RA on trach mask
GEN: ill appearing, non responsive
HEENT: no rashes,
CV: rrr s1 s2, no M/G/R
RESP: CTA ant
ABD: soft, NT/ND
EXT: no edema or excoriations
NEURO: deffered
.
Discharge exam: (notable findings)
T 96.9 Tm 99.2 BP 95/74 HR 88-100 RR 20 94% trach mask 35%
General: minimally responsive elderly male with trach, NAD
Neuro: tracks people with eyes (EOMI PERRL), needs glasses on to
see, does not respond in meaningful way to questions, does
follow some commands (squeeze finger, spread fingers, blinks,
moves limbs spontaneously, L arm lightly contracted but able to
move passively, does not wiggle toes. Some days he waves hello
and some days he mouths words though unclear what he is trying
to say.
Respiratory: trach w/35% trach mask, white-light yellow sputum
requiring frequent suctioning, rhonchi heard throughout
CV: RRR no m/r/g, distant heart sounds
Abd: soft, NT/ND, PEG c/d/i, functioning well
Limbs/extremities: old excoriations on L arm, no edema, brown
mottling/discoloration of dorsal feet b/l, dopplerable pulses
Pertinent Results:
[**2171-10-15**] 08:55PM BLOOD WBC-21.8*# RBC-4.20*# Hgb-12.9*#
Hct-38.7*# MCV-92 MCH-30.6 MCHC-33.2 RDW-16.9* Plt Ct-287
[**2171-10-15**] 08:55PM BLOOD Neuts-93.3* Bands-0 Lymphs-4.2* Monos-2.0
Eos-0.4 Baso-0.1
[**2171-10-18**] 02:39AM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-OCCASIONAL Stipple-1+
[**2171-10-19**] 05:20AM BLOOD WBC-10.7 RBC-3.16* Hgb-9.7* Hct-29.1*
MCV-92 MCH-30.8 MCHC-33.5 RDW-17.0* Plt Ct-57*
[**2171-10-23**] 05:17AM BLOOD WBC-12.7* RBC-3.30* Hgb-10.5* Hct-30.8*
MCV-93 MCH-31.9 MCHC-34.2 RDW-18.2* Plt Ct-211
[**2171-10-31**] 04:31AM BLOOD WBC-8.3 RBC-2.99* Hgb-9.3* Hct-28.0*
MCV-94 MCH-31.1 MCHC-33.2 RDW-17.7* Plt Ct-289\
[**2171-11-2**] 10:57AM BLOOD Neuts-64.9 Lymphs-23.1 Monos-5.0 Eos-6.7*
Baso-0.3
[**2171-11-12**] 04:05AM BLOOD WBC-8.9 RBC-2.96* Hgb-9.4* Hct-27.9*
MCV-94 MCH-31.9 MCHC-33.8 RDW-17.6* Plt Ct-345
[**2171-11-14**] 04:30AM BLOOD WBC-10.7 RBC-3.36* Hgb-10.4* Hct-31.1*
MCV-93 MCH-31.0 MCHC-33.5 RDW-17.2* Plt Ct-308
.
[**2171-10-15**] 08:55PM BLOOD Glucose-206* UreaN-69* Creat-2.2* Na-135
K-4.8 Cl-101 HCO3-19* AnGap-20
[**2171-10-17**] 05:00AM BLOOD Glucose-94 UreaN-63* Creat-2.4* Na-142
K-4.2 Cl-111* HCO3-20* AnGap-15
[**2171-10-21**] 12:47PM BLOOD Glucose-113* UreaN-38* Creat-2.0* Na-138
K-4.4 Cl-108 HCO3-23 AnGap-11
[**2171-11-12**] 04:05AM BLOOD Glucose-93 UreaN-37* Creat-1.6* Na-141
K-4.0 Cl-111* HCO3-23 AnGap-11
[**2171-11-14**] 04:30AM BLOOD Glucose-89 UreaN-34* Creat-1.8* Na-139
K-4.5 Cl-106 HCO3-24 AnGap-14
.
[**2171-10-16**] 01:21AM BLOOD PT-14.8* PTT-26.9 INR(PT)-1.3*
[**2171-10-23**] 05:17AM BLOOD PT-13.2* PTT-27.3 INR(PT)-1.2*
[**2171-11-10**] 04:45AM BLOOD PT-14.6* PTT-28.0 INR(PT)-1.3*
[**2171-10-15**] 08:55PM BLOOD ALT-55* AST-43* AlkPhos-312* Amylase-76
TotBili-0.4
[**2171-10-16**] 04:00PM BLOOD ALT-54* AST-45* AlkPhos-257*
[**2171-10-23**] 05:17AM BLOOD ALT-40 AST-40 AlkPhos-268* TotBili-0.3
[**2171-10-15**] 08:55PM BLOOD Lipase-56
[**2171-10-22**] 04:57AM BLOOD Lipase-114*
[**2171-10-16**] 01:21AM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.5 Mg-2.6
[**2171-11-14**] 04:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.7*
[**2171-11-6**] 03:02AM BLOOD TSH-2.7
[**2171-11-2**] 11:32PM BLOOD Type-ART pO2-64* pCO2-40 pH-7.37
calTCO2-24 Base XS--1
[**2171-11-3**] 01:02AM BLOOD Type-ART pO2-80* pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2171-10-15**] 09:08PM BLOOD Lactate-2.4*
[**2171-10-16**] 01:32AM BLOOD Lactate-2.0
[**2171-10-15**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-15**] 09:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2171-10-15**] 09:00PM URINE RBC-0-2 WBC-[**3-4**] Bacteri-FEW Yeast-MOD
Epi-0
[**2171-11-8**] 03:13PM URINE RBC-[**6-9**]* WBC->50 Bacteri-MANY Yeast-MANY
Epi-0
[**2171-11-8**] 03:13PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2171-11-8**] 03:13PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2171-11-8**] 03:13PM URINE RBC-[**6-9**]* WBC->50 Bacteri-MANY Yeast-MANY
Epi-0
[**2171-10-18**] 06:06PM URINE Hours-RANDOM UreaN-660 Creat-37 Na-98
[**2171-10-18**] 06:06PM URINE Osmolal-502
[**2171-11-9**] 09:31PM URINE Color-S Appear-CL Sp [**Last Name (un) **]-1.010
[**2171-11-9**] 09:31PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2171-11-9**] 09:31PM URINE RBC-[**11-19**]* WBC-[**3-4**] Bacteri-MOD Yeast-MOD
Epi-<1
.
MICROBIOLOGY
[**2171-11-9**] 9:31 pm URINE Site: NOT SPECIFIED**FINAL REPORT
[**2171-11-11**]**
URINE CULTURE (Final [**2171-11-11**]): YEAST. >100,000
ORGANISMS/ML..
[**2171-11-9**] [**2171-11-9**] 4:28 pm SWAB Site: HIP LEFT HIP.
GRAM STAIN (Final [**2171-11-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2171-11-11**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2171-11-13**]**
GRAM STAIN (Final [**2171-11-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
SMEAR REVIEWED; RESULTS CONFIRMED.
[**Month/Day/Year **] CULTURE (Final [**2171-11-13**]):
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).
ENTEROCOCCUS SP.. SPARSE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
YEAST. RARE GROWTH. 2ND TYPE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2171-11-13**]): NO ANAEROBES ISOLATED.
.
[**2171-11-8**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-11-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NG
[**2171-11-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NG
[**2171-11-2**] GRAM STAIN (Final [**2171-11-3**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2171-11-6**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. 2ND COLONIAL
MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- 1 S 1 S
GENTAMICIN------------ 2 S <=1 S
IMIPENEM-------------- =>16 R =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 64 S =>128 R
PIPERACILLIN/TAZO----- 64 S =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
.
[**2171-11-2**] URINE Legionella Urinary Antigen NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2171-11-2**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT >100,000
ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES
[**2171-10-29**] STOOL FECAL CULTURE (Final [**2171-10-31**]): NO
SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final
[**2171-10-31**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE
TOXIN ASSAY (Final [**2171-10-30**]): FECES NEGATIVE FOR C. DIFFICILE
TOXIN BY EIA.
[**2171-10-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT NG
[**2171-10-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT NG
[**2171-10-16**] FECAL CULTURE (Final [**2171-10-19**]): NO SALMONELLA OR
SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2171-10-18**]): NO
CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final
[**2171-10-17**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2171-10-15**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA,
KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] URINE CULTURE (Final
[**2171-10-21**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 32 R <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- 8 I <=1 S
MEROPENEM------------- 4 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 32 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2171-10-15**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **] NG
[**2171-10-15**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **] NG
.
[**10-15**] ECG Probable marked resting sinus tachycardia at about 136
beats per minute, although atrial tachycardia is not excluded.
Borderline left axis deviation. Possible right or biatrial
abnormality. Possible prior inferior wall myocardial infarction.
Left ventricular hypertrophy. Underlying anterior Q wave
myocardial infarction. Non-specific ST-T wave changes. Compared
to previous tracing of [**2171-8-16**] the heart rate is markedly
increased. QTc interval prolongation is not noted. Lateral T
wave inversions are normalized. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
136 148 86 306/439 64 -24 143
.
IMAGING
[**10-15**]
PORTABLE UPRIGHT CHEST RADIOGRAPH: Minimal amount of linear
atelectasis is noted at the lung bases bilaterally with the
lungs appearing otherwise clear. Cardiomediastinal silhouette,
hilar contours, and pleural surfaces are within normal limits
and unchanged. Tracheostomy tube terminates approximately 4.8 cm
from the carina and left PICC terminates in the brachiocephalic
junction/superior SVC. Previously identified surgical/drainage
catheter projecting over the left upper quadrant is no longer
visualized.
.
[**10-16**] portable CXR- The tracheostomy tube is approximately 5 cm
above the carina. The left PICC line terminates in the upper
SVC/brachiocephalic junction. There are persistent low lung
volumes. There is increased right lower lobe linear opacities
likely consistent with atelectasis. There is no pneumothorax.
There are no focal consolidations or effusions.
.
[**10-16**] RUQ US FINDINGS: Grayscale and color ultrasound imaging of
the liver was performed with comparison made to CT examination
of [**2171-7-1**]. Again seen are multiple shadowing stones within the
gallbladder lumen. There is no gallbladder wall thickening or
pericholecystic fluid. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was not
elicited. Body habitus limits thorough evaluation, however, no
definite focal hepatic lesions are seen. There is no ascites.
Two small hepatic cysts are seen, consistent with prior CT
findings. Portal vein remains hepatopetal in flow
direction.IMPRESSION: Cholelithiasis without son[**Name (NI) 493**]
evidence for acute cholecystitis.
.
Portable AP chest dated [**2171-11-1**] is compared to the prior from
[**2171-10-18**].
Tracheostomy tube is in stable position. The left PICC line has
migrated approximately 2.5 cm and is now positioned in the
distal left subclavian vein. The heart size and mediastinal
contours are unchanged given patient positioning. Lung volumes
are low, but there is no evidence of airspace consolidation,
pleural effusion, or pneumothorax.IMPRESSION: Interval
retraction of PICC approximately 2.5 cm, now terminating in the
distal left subclavian vein.
.
[**2171-11-7**] Portable AP chest radiograph compared to [**2171-11-5**]. The tracheostomy tube is in unchanged central position.
The mild-to-moderate cardiac enlargement is stable as well as
the mediastinal widening. The lungs are overall clear except for
right retrocardiac area where small opacity is demonstrated and
might represent either atelectasis or pneumonia, unchanged since
the previous study. There is no pleural effusion or
pneumothorax. Left PICC line tip terminates in left
brachiocephalic vein, unchanged since the previous study.
.
[**2171-11-11**] IMPRESSION: Successful declogging of G-tube using an
Amplatz wire and saline. The tube is ready for use.
Brief Hospital Course:
61 y/o man w/multiple medical problems including CAD complicated
by anoxic brain injury, with multiple infectious foci admitted
with an episode of hypoxia, tachycardia, fevers and hypotesion
likely secondary to urosepsis. Hospital course by problem:
.
# Hypotension/Sepsis: The patient's BP was in the 70s systolic
and he was admitted to ICU from the ED. He was occasionally
hypotensive to SBP in the 80s in the MICU, but he responded
quickly to fluids and antibiotics and he was soon called out to
the floor. On the floor he was continued on antibiotics and was
clinically improving, awaiting placement, but he had increased
secretions requiring frequent suctioning so he was transferred
back to the MICU and then back to the floors once secretions
were under better control. His blood pressures remained stable
with SBPs in the 90s-110s,
the patient is currently afebrile and normotensive. The
combination of fevers, hypotension, and elevated WBC count
support the diagnosis of sepsis. Possible sources included
pulmonary source, [**Month/Day/Year **], possible line infections(PICC x 6 wks),
urinary and abdominal source (cholecystitis as possibly
suggested by elevated LFT's). CXR was normal, [**Month/Day/Year **] cultures
from [**Hospital1 **] showed pseudomonas and proteus species, but blood
cultures have been negative. No obvious areas of erythema were
seen around the pick site or sacral decubitus ulcer. RUQ US
showed no cholecystitis or biliary disease. Urine cultures grew
klebsiella as a likely source. The patient was started on Zosyn
for pseudomonas and klebsiella coverage and switched to
meropenem due to thrombocytopenia. (See below).
.
# Hypoxia/Respiratory Secretions: His initial hypoxia was
thought to be due to transient mucus plugging. His hypoxia
resolved in the MICU with trach care and suctioning however when
he was on the floors he was noted to have increasing secretions
which appeared benign and related to the patient's inability to
manage secretions, however the nursing staff could not meet his
suctioning needs so he was transferred back to the MICU for more
frequent suctioning. In the ICU, he had more yellow and thick
secretions, so there was concern for possible pneumonia,
especially given that he developed a low grade fever and
tachycardia, however those have resolved. His chest x-rays have
not revealed any clear new consolidation, so it is felt at this
time he does not have a PNA. Patient is not hypoxic. With the
addition of tobramycin nebs [**Hospital1 **] and sublingual levsin, his
secretions decreased. The patient also completed a 4 day course
of Prednisone (60 mg PO x4 days) for possible COPD/bronchitis
component in the MICU. His sputum culture grew Pseudomonas
(meropenem resistant), but the consensus is that the patient is
likely colonized. He has been continued on Tobramycin nebs [**Hospital1 **]
to assist with mucous secretions for Pseudomonas colonization
(this is often given to patients with Cystic Fibrosis) with the
plan to continue Tobramycin nebs for 2 weeks, started on
[**2171-11-6**], to complete course on [**2171-11-20**]. He requires suctioning
to assist in clearing secretions (at least q3hrs) and
additionally receives atrovent, fluticasone, and xoponex in
place of albuterol (due to tachycardia) to manage COPD symptoms.
The patient may benefit from scopalamine patches in the future
if his secretions worsen and this may be discussed with his
family.
.
#UTI: In the MICU the patient was started on vanc/zosyn/flagyl
for sepsis. However, urine cultures grew pseudomonas and
klebsiella and [**Date Range **] cultures from [**Hospital1 **] grew proteus and
pseudomonas sensitive to imipenem, and he was colonized with
pseudomonus in the lungs, so vanc/zosyn/flagyl were discontinued
and he was started on meropenem (for pseudomonas both in the
urine and possibly in the bone- osteomyelitis- as pseudomonas
grew from the coccyx [**Hospital1 **] as well). The patient is being
treated for UTI and osteomyelitis (klebsiella and pseudomonas),
with meropenem for a 6wk course (day 1 = [**10-18**], the last day
will be [**11-29**]).
.
# History of sacral decubitus ulcer complicated by osteomyelitis
(MSSA+ s/p 6 weeks vancomycin at [**Hospital1 **]). As part of the
sepsis work up the patient was found to have pseudomonas
sensitive to imipenem in his sacral ulcer [**Hospital1 **] so was started
on meropenem as above. A sputum culture grew Pseudomonas
resistant to Meropenem, so there was concern that the sacral
[**Hospital1 **] could have pseudomonas resistant to Meropenem as well and
a repeat sacral [**Hospital1 **] culture was obtained on [**2171-11-9**] which did
not grow pseudomonas but is growing VRE. It is thought this is
likely contamination from feces as the clinical exam does not
support cellulitis. Osteomyelitis by VRE could be possible but
since the patient has been afebrile with no leukocytosis for the
past weeks, we chose not to treat and trend his fever curve and
WBC. One can consider adding linezolid to his antibiotics (14
days for cellulitis) or daptomycin (for longer course if suspect
osteo) if the patient develops signs of active infection. During
the hospital stay a [**Date Range **] nurse evaluated him and his [**Date Range **] was
managed per the [**Date Range **] nurse recommendations. Plastics was also
consulted and recommended continuing the current care, and to
maximize nutrition and blood glucose control to assist in
healing. The patient completed a 14 day course of Vit C and Zinc
for sacral decub care started on [**10-22**].
.
# Thrombocytopenia: The patient's platelets decreased over the
first 2 days of his hospital stay with a nadir on [**10-18**]. Zosyn
was discontinued (changed to meropenem) on [**10-18**] and his
platlets subsequently increased. HIT antibody was negative, so
heparin was restarted on [**10-19**]. Patelets continued to increase.
.
# CAD: Per past reports his coronary artery disease is
non-revascularizable, and he is allergic to betablockers. He was
continued on ASA 81 and a statin.
.
# CHF, systolic: The patient was bolused with gental IVF when
needed for hypotension in his initial few days of admission.
Also his ins and outs were monitored and he demonstrated equal
fluid balance. He did not demonstrate signs of fluid overload.
.
# DM: NPH was increased to 7 qAM and 8 qPM, FSBG under better
control, also with RISS.
.
# Acute on chronic renal failure: The patient's creatinine
varied widely in the past. On presentation his Cr was elevated,
thought to be due to hypovolemia. His Cr came back to baseline
at 1.6-1.8 with fluid resuscitation.
.
# History of atrial fibrillation: The patient is not rate
controlled or anticoagulated but he had a normal rhythm during
his stay. He occasionally becomes tachycardic with persistent
HRs in the 100s but this seems to have resolved with using
xopinex instead of albuterol for nebulizers. He tends to get
more tachycardic (120a) after suctioning and when he is
uncomfortable. His tachycardia is felt less likely to be due to
infection as he has been afebrile, and has a normal WBC count,
and is on Meropenem. He is still somewhat tachy with baseline HR
in the 80s-100s
.
# Altered MS - Multifactorial in etiology and chronic.
Contributants include: anoxic brain injury, demylenating
disease, known dementia, prior CVA,and h/o thought disorder. He
is able to follow some commands, and his mental status has
improved during the course of his admission.
.
# Agitation: Patient had been scratching his upper extremities
with multiple excoriations, likely due to agitation. He was
given Ativan 0.5 mg IV Q4H:PRN aggitation and was started on
Hydroxyzine 50 mg PO Q6H:PRN anxiety. He has fewer excoriations,
just on L arm now.
MICU, continue.
.
# Anemia- likely anemia of chronic disease, cont to trend
.
# FEN: tube feeds via peg, recently de-clogged, tube feeds at
goal.
.
# PPx: Heparin SQ, pneumoboots, sucralfate (as pt had
thrombocytopenia and was taken off PPI), bowel regimen
.
# CODE: FULL
.
# DISPO: To [**Hospital 3058**] rehab. placement has been a problem for
him due to insurance issues.
.
# Communication: Brother/HCP [**Name (NI) 11312**] [**Name (NI) 14714**]
Medications on Admission:
colace 100 mg po bid
bisacodyl suppositories prn for constipation
heparin 5,000 u sq q8hr
reglan 5 mg po tid
miconazole nitrate one application [**Hospital1 **]
amantadine 50 mg po bid
ascorbic acid 90 mcg [**Hospital1 **]
albuterol mdi q2hr prn
glycerine suppositories pr prn constipation
lactulose 30 ml qday prn constipation
senna 2 tabs [**Hospital1 **] pern constipaton
scopolamine patch 1.5 mg q2hr
simvastatin 10 mg po daily
zinc sulfate 220 mg po daily
tylenol 650 mg q6hr prn pain
asa 81 mg po daily
Discharge Medications:
Please see discharge summary for antibiotic course instructions.
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: Five
(5) ml Inhalation [**Hospital1 **] (2 times a day).
14. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML
Inhalation q4h ().
15. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for anxiety.
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
18. Meropenem 500 mg IV Q8H
19. Lorazepam 0.5 mg IV Q4H:PRN anxiety
hold for HR < 70 or SBP < 110
20. other Sig: see instructions for insulin n/a see below:
NPH 7 units bkfst NPH 8 units bedtime
Humolog ISS at bkfst, lunch, dinner and bedtime:
0-50 4 oz juice
51-149 0 units
150-199 2 units
200-249 4 units
250-299 6 units
300-349 8 units
350-399 10 units
>400 notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
1. Urosepsis
Secondary
2. Coronary artery disease 3 vessel disease, status post cardiac
arrest CAD
3. Anoxic brain injury (from cardiac arrest)
4. ischemic cardiomyopathy (EF 25%)
5. Osteomyelitis - recently diagnosed ([**7-/2171**])
6. sacral decubitus ulcer- Methicillin Sensitive Staph aureus
positive
7. Sensorimotor demyelinating polyneuropathy
8. suspected colonization of airway with pseudomonas (pan
sensitive)
9. chronic renal insufficiency, known horseshoe kidney
10.chronic indwelling foley
11. history of atrial fibrillation (currently not
anticoagulated, not rate controlled, and not in atrial
fibrillation
12. Hyperlipidemia
13. history of abdominal aortic aneurysm
14. Schizophrenia
15. prior strokes seen on CT head
16. history of dementia
Discharge Condition:
Fair
Discharge Instructions:
You were admitted to the hospital for hypoxia, fevers, and
tachycardia. While in the hospital you were found to have a
urinary tract infection as well as organisms growing from your
sacral [**Year (4 digits) **] and from your sputum and were started on
antibiotics to treat these infections. While in the ICU your
blood pressure was low but came back up after receiving some IV
fluids. You were noted to have increased secretions from your
trach tube. Your sputum grew pseudomonas - we do not think this
is an infection, but rather colonization. We gave you levsin and
a scopolamine patch which helped decrease your secretions and
suctioned your trach regularly.
.
Please continue to take your antibiotic (Meropenem) to complete
a 6 week course.
.
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* [**Name2 (NI) **] have shaking chills or fevers greater than 102 degrees(F)
or lasting more than 24 hours.
* You aren't getting better within 48 hours, or you are getting
worse.
* New or worsening pain in your abdomen (belly) or your back.
* You are vomiting, especially if you are vomiting your
medications.
* Your symptoms come back after you complete treatment.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) 6923**] [**Name (STitle) 6924**] on Thursday
[**12-5**] at 2:10pm at the [**Hospital3 4262**] Group [**Street Address(1) 64339**]. If you need to reschedule, please call their office at
[**Telephone/Fax (1) 608**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2171-11-14**]
ICD9 Codes: 5849, 5990, 5859, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4546
} | Medical Text: Admission Date: [**2152-11-29**] Discharge Date: [**2152-12-5**]
Date of Birth: [**2152-11-29**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname **] is a 34-5/7 week gestation
female infant admitted to the Neonatal Intensive Care Unit
because of prematurity after cesarean section delivery in the
main operating room.
PREGNANCY: Mother is a 34-year-old G4, P3 now 4 woman.
PRENATAL SCREENS: O positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative.
Pregnancy was complicated by maternal diabetes treated with
insulin. Delivery was planned at 34-5/7 weeks electively
because of placenta previa and accreta and was performed in
the main OR because of concern for potential maternal
hemorrhage and the need of hysterectomy, which was
subsequently performed.
The baby emerged with good tone and cry after delivery.
Apgars were 8 at one minute and 9 at five minutes. She
received bulb suctioning and blow-by oxygen briefly. She was
transported to the Neonatal Intensive Care Unit because of
prematurity and did not have respiratory distress.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 2095 (50th
percentile), length 43 cm (25th percentile), head
circumference 32.5 cm (50th-75th percentile). Baby is [**Name2 (NI) **],
alert with excellent tone. Anterior fontanel is soft and
flat, normal faces, palate intact. Lung sounds clear and
equal, no retractions, comfortably tachypneic. No murmur,
normal S1, S2. Abdomen is soft, no organomegaly. Normal
female genitalia. Neurologic: Good tone, symmetrical
examination. Hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Infant has remained
in room air throughout this hospitalization with respiratory
rates 50s-60s and oxygen saturation greater than 98%. Infant
has not had any apnea or bradycardia this hospitalization.
Cardiovascular: Infant has remained hemodynamically stable
this hospitalization, no murmur, heart rate 120s-140s with
mean blood pressures 39-56.
Fluids, electrolytes, and nutrition: Infant was initially
nothing by mouth receiving 60 cc/kg/day of D10W IV. Enteral
feedings were started on day of life one, and the infant is
currently taking total fluids of 150 cc/kg/day of Prosobee 20
calories/ounce p.o. The infant is requiring some gavage
feedings at this time.
Electrolytes on day of life three showed a sodium of 143,
chloride of 111, potassium of 4.4, pCO2 of 19. The most
recent weight is [**2104**] gms.
GI: Phototherapy was started on day of life five for a
bilirubin level of 9.7 and direct of 0.4. Repeat bilirubin
after a day of phototherapy was 7.8/0.3. Phototherapy was
discontinued and a rebound bilirubin check will need to be
obtained for the am ([**2152-12-6**]).
Hematology: A CBC and blood culture were drawn on admission
for mild tachypnea. The white blood cell count was 11.9,
hematocrit 48.6%, platelets 321,000, 20 neutrophils, 0 bands.
Blood culture remains negative to date. Infant has not
received any transfusions this hospitalization.
Infectious disease: Blood culture was drawn on admission and
remains negative to date.
Neurology: Normal neurologic examination.
Sensory: Hearing screening is recommended prior to
discharge.
CONDITION ON DISCHARGE: A 34-5/7 weeks, now 35-4/7 weeks
corrected, stable on room air.
DISCHARGE DISPOSITION: Level 2 nursery [**Location (un) 48238**], [**Location (un) 7498**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4401**], phone
number [**Telephone/Fax (1) 53618**] in [**Location (un) **], [**State 1727**]. Receiving pediatrcian: Dr.
[**Last Name (STitle) 7356**] [**Telephone/Fax (1) 53619**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: 150 cc/kg/day of Prosobee 20
calories/ounce p.o./pg.
2. Medications: None.
3. Car seat position screening is recommended prior to
discharge.
4. State Newborn Screen was sent on [**12-2**], the
results are pending.
5. Immunizations: Parents do not want the infant to receive
hepatitis B vaccine at this time, will need prior to discharge
to home.
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with two of three of
the following: daycare during RSV season, with a smoker in
the household, neuromuscular disease, airway abnormalities,
or school-age siblings, or 3) with chronic lung disease.
DISCHARGE DIAGNOSES:
1. Prematurity 34-5/7 week female.
2. Status post rule out sepsis.
3. Indirect hyperbilirubinemia.
[**First Name8 (NamePattern2) 39464**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2152-12-4**] 23:09
T: [**2152-12-5**] 06:03
JOB#: [**Job Number 53620**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4547
} | Medical Text: Admission Date: [**2159-1-31**] Discharge Date: [**2159-2-4**]
Date of Birth: [**2128-11-13**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Altered Mental Status, Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30M with history of substance abuse, Hep C, depression,
presenting after found unresponsive in car, now admit to MICU
with hypoxia. He was found hypothermic and unresponsive in his
car. EMS gave his intranasal and then IM narcan, then woke up.
He admitted to using heroin and cocaine last night. He was
brought to OSH. Found to be 89 degrees. CXR with pulmonary
edema. CT head negative. Labs with ARF and CK 1300. Given
another 1mg IV dose of narcan, ceftriaxone, azithro, and vanco
for antibiotics, as well as solumedrol 125 mg IV. ASA given
rectally. Also gave lasix IV. Briefly hypotensive to 80s. CT
head negative.
.
In the [**Hospital1 18**] ED, initial vs were: T96.5 P102 96/55 16 96% NRB.
Awake and alert. Does complain of some shortness of breath.
EKG with ST, no ischemic changes. Patient was given 3 L IVFs
and started on BiPAP.
.
In the MICU, patient sleepy but awake. Recalls using heroin and
cocaine last night (all IVDU, no snorting or smoking recently);
no other drugs or meds, no EtOH. Does not remember anything
until the ambulance bringing patient from OSH to [**Hospital1 18**]. Denies
current chest pain or abdominal pain, though did note having
both of those intermittently during ED stay. Notes that he was
clean for 18 months until he relapsed last night. No baseline
pulmonary disease and has at least fair baseline exercise
tolerance (can go up flights of stairs without symptoms).
.
Review of systems:
(+) Per HPI. Endorses feeling tired lately.
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, cough, hemoptysis, wheezing. Denies palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
- Hepatitis C
- Depression (?bipolar depression - patient denies this as past
diagnosis but endorses periods of staying up all night/increased
energy in absence of drug use).
- Childhood asthma (no symptoms or med use x years)
Social History:
Lives with girlfriend and new puppy. Works in a hotel.
- Tobacco: No recent smoking; former smoker now quit.
- Alcohol: Denies EtOH use.
- Illicits: Heroin and cocaine IV last night as above. Prior
history of using other drugs and in other forms (smoking,
inhaling) but none in a few years.
Family History:
Grandmother with lung cancer; some on father's side of the
family have unknown heart problems. [**Name (NI) **] pulmonary history.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Sleepy though awake and oriented, no distress, no
accessory muscle use. Answering questions and following
commands appropriately without falling asleep.
HEENT: Sclera anicteric, PERRL 3->2, MM dry, oropharynx clear.
Neck: supple, JVD to 2-3 cm ASA, no LAD
Lungs: Clear to auscultation bilaterally without wheeze or
rhonchi, though slightly poor air entry.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, diffuse
tenderness to palpation throughout abdomen, no rebound
tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: CN II-XII intact. [**5-23**] UE and LE distal strength.
Pertinent Results:
Labs On Admission:
[**2159-1-31**] 08:07PM CK(CPK)-2990*
[**2159-1-31**] 08:07PM CK-MB-104* MB INDX-3.5 cTropnT-0.02*
[**2159-1-31**] 02:57PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-1-31**] 02:57PM URINE RBC-[**3-23**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**3-23**]
[**2159-1-31**] 11:21AM GLUCOSE-84 NA+-140 K+-4.4 CL--105 TCO2-23
[**2159-1-31**] 11:20AM UREA N-25* CREAT-1.6*
[**2159-1-31**] 11:20AM cTropnT-0.06*
[**2159-1-31**] 11:20AM CK-MB-94* MB INDX-5.0 proBNP-787*
[**2159-1-31**] 11:20AM WBC-8.1 RBC-4.64 HGB-13.6* HCT-40.4 MCV-87
MCH-29.4 MCHC-33.7 RDW-13.6
[**2159-1-31**] 11:20AM NEUTS-91* BANDS-0 LYMPHS-7* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
Labs on Discharge:
[**2159-2-4**] 07:05AM BLOOD WBC-6.7 RBC-4.76 Hgb-13.9* Hct-40.8
MCV-86 MCH-29.3 MCHC-34.2 RDW-13.8 Plt Ct-235
[**2159-2-4**] 07:05AM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-141
K-4.2 Cl-103 HCO3-27 AnGap-15
[**2159-2-4**] 07:05AM BLOOD ALT-52* AST-44* CK(CPK)-209
[**2159-2-1**] 02:38AM BLOOD CK-MB-69* MB Indx-2.9 cTropnT-<0.01
[**2159-2-2**] 06:20AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2159-2-2**] 06:20AM BLOOD HIV Ab-NEGATIVE
[**2159-2-2**] 06:20AM BLOOD HCV Ab-POSITIVE*
Studies:
ECHO: No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate global left ventricular hypokinesis
(LVEF = 40 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size is mildly dilated with mild global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Biventricular cardiomyopathy
CXR: Bilateral airspace opacities, with some sparing of the
periphery,
findings may be secondary to pulmonary edema, although
superimposed infectious process cannot be excluded.
CT chest:
IMPRESSION:
1. Bilateral diffuse ground-glass opacity. Given symmetry, this
may
represent pulmonary edema, although with the history of
hemoptysis and drug abuse, pulmonary hemorrhage and
opportunistic infectious process cannot be excluded.
2. Prominent mediastinal lymph nodes, likely reactive.
3. Small right pleural effusion and bibasilar atelectasis.
4. Splenomegaly.
HIV-1 Viral Load/Ultrasensitive (Final [**2159-2-5**]):
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
Detection range: 48 - 10,000,000 copies/ml.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
HCV VIRAL LOAD (Final [**2159-2-5**]):
HCV-RNA NOT DETECTED.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Micro:
[**2159-2-1**] BLOOD CULTURE Blood Culture, Routine-negative
[**2159-1-31**] BLOOD CULTURE Blood Culture, Routine-negative
[**2159-1-31**] URINE Legionella Urinary Antigen -negative
Brief Hospital Course:
30M with polysubstance abuse, depression; admitted to MICU with
hypoxia after found down after IV cocaine/heroin use.
.
# Hypoxia. In setting of IV cocaine and opiate abuse. Also
with bilateral pulmonary infiltrates. Likely combination of
hypoventilation from opiate overdose in addition to effects of
IVDU - likely a noncardiogenic pulmonary edema from heroin or
cocaine abuse. Less likely "crack lung" without wheezing,
fever, eosinophilia. No evidence of pulmonary hemorrhage.
Effects on coronaries with development of cardiogenic pulmonary
edema were also a consideration, but no ECG changes, elevation
in troponin, or chest pain - less likely. Injection drug use
can also cause more chronic ILD, but this appears to be an acute
process. Other considerations included typical multifocal CAP,
aspiration pneumonia or pneumonitis. CXR showed persistence of
left sided infiltrate and patient was hypoxic w/ minimal
hemoptysis upon transfer from ICU to floors, so patient was
assumed to have aspirated. Patient given course of
levaquin/flagyl. In addition, prior to discharge, evidence of
fluid on CT chest(possibly from overagressive IVF as below), so
he did have diuresis with lasix prior to discharge. He was
saturating >92% with ambulation on room air upon discharge.
.
# Acute renal failure. Resolved upon discharge. DIfferential
included prerenal, ATN from rhabdo (though CK elevation rather
mild), ATN from hypotension or other drug exposures, less likely
vasoconstriction/infarction. Resolved with fluids.
.
# Elevated CK. Mildly elevated; likely from cocaine induced
muscle damage. CKMB index borderline but troponins were low and
cycled. Maintained on IVF in the ICU, oral fluids on the general
medical floors.
.
# Episode of unresponsiveness. In field, likely due to
heroin/opiate overdose. Also hypothermic. Considered infection
also as possibility. CT head negative.
Gabapentin originally held because of sedation, but reinstituted
upon discharge.
.
# Hypothermia. Likely from exposure; no evidence of
hypoglycemia, sepsis, hypothyroidism.
.
# Polysubstance abuse, depression. Relapsed after 18 months of
being clean. Did admit to feeling depressed lately, but denied
SI inhouse. Psychiatry was in touch with outpatient therapist
and did not recommend any changes to medication regimen. Social
work and addictions counseler also saw patient inhouse.
Discharged on home psych meds, will f/u with PCP as outpatient.
Patient also tested for HIV (viral load and antibody), which
were negative. Attempted to contact patient, but not available
by phone. Contact[**Name (NI) **] outpatient PCP, [**First Name4 (NamePattern1) 22917**] [**Last Name (NamePattern1) **], who will convey
these results to patient on his appointment this week. Patient
instructed to use condoms with girlfriend and have repeat
testing in [**8-30**] weeks.
.
# Hepatitis C. s/p treatment. HCV viral load not detectable.
Result conveyed to PCP, [**Name10 (NameIs) **] will be conveyed to patient in that
manner.
Medications on Admission:
Gabapentin 800 mg PO/NG Q8H
Omeprazole 20 mg PO DAILY
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Levofloxacin 750 mg PO/NG DAILY
BuPROPion (Sustained Release) 150 mg PO BID
Heparin 5000 UNIT SC TID
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN Constipation
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/HA: don't exceed 2 grams in 24
hours.
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
4. Wellbutrin XL 300 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
5. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Drug overdose
2. Hypoxia
3. Community acquired pneumonia
4. Acute renal failure
5. Polysubstance Abuse
6. Depression
SECONDARY DIAGNOSIS:
1. History of hepatitis C
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 because you were found
unresponsive after a drug overdose, and you had to be admitted
to the intensive care unit. There, we gave you medication to
reverse the effects of the drugs you had taken. You have also
been coughing up blood and feeling short of breath. We suspect
that this is because of a pneumonia. You should take an
additional three days of antibiotics when you leave here for
this. If the coughing does not subside, or you start coughing up
more than a cupful of blood, please call your PCP or go to the
ED.
You were seen by the psychiatry team and the addictions social
worker inhouse, with regard to your depression and your drug
abuse. Please follow their recommendations to help keep you from
using drugs again. You will also need to follow up with Dr.
[**First Name (STitle) **], who has managed your addiction in the past. You were not
feeling suicidal while you were hospitalized, but if you do feel
this way, go to the ER immediately.
If you are having pain, you can take tylenol only sparingly (no
more than 2 grams total in 24 hours) because your liver function
tests are still not completely normal. You must avoid all
alcohol for this reason as well.
You should take one more day of moxifloxacin for one more day to
complete a course of antibiotics for pneumonia
We tested you for HIV and hepatitis as well. These results were
pending at the time of your discharge, and must be followed up.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 250**] will follow up these results with
you within the next 2 weeks. As we discussed, even if these
results are negative, you should have a repeat HIV test in [**2-21**]
months, and you must use condoms everytime you have sexual
intercourse.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] at [**Location (un) 246**] Family Practice
[**Telephone/Fax (1) 71360**] on Wednesday at 10am.
ICD9 Codes: 5849, 5070, 4254, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4548
} | Medical Text: Admission Date: [**2140-11-18**] Discharge Date: [**2140-11-25**]
Date of Birth: [**2079-2-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
cough, shortness of breath
Major Surgical or Invasive Procedure:
intubation, central line, arterial line
History of Present Illness:
61 yo F with PMH of asthma (no prior intubations), OSA (does not
wear CPAP), HTN, and depression who p/w shortness of breath,
fevers and chills. She suddenly developed acute onset of
shortness of breath and sharp chest pain lasting seconds this
afternoon. Has also noted that her legs have been getting more
swollen recently, denies calf pain. Also had n/v x2,
nonbloody/nonbilious and diarrhea x5 today, no abdominal pain.
.
In ED, Tmax 101.6, RR 24-40, satting 89%RA -> 93-97% on 3L. RR
decreased. On exam, pt with audible crackles and wheezing
throughout lung fields. CXR with LLL pneumonia. Her lab showed
lactate of 3.4, and she received 1L NS bolus. Despite the fluid,
she became more hypotensive with SBP ~80-90s. L subclavian line
was placed and she was started on levophed. She received total
of 4.5 L NS in the ED. Per report, her breathing became more
labored and she was intubated. Also received tylenol,
ceftriaxone, and azithromycin.
.
On arrival to the ICU, patient is intubated and sedated. Unable
to get further history. Attempted to call her husband and left a
voice mail.
Past Medical History:
1. Asthma
2. Obstructive sleep apnea
3. Hypertension
4. GERD
5. Depression
6. Anxiety
7. Osteoarthritis
8. Remote history of basal cell carcinoma, resected ~15+ years
ago
Social History:
Unable to obtain
Family History:
Unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP: P: R: 18 O2:
General: obese woman, intubated, sedated.
HEENT: Sclera anicteric, ETT in place, pinpoint pupil but equal
Lungs: Clear to auscultation on R side, decreased breath sounds
LLL. Rhonchorous/mechanical ventilation sounds throughout.
CV: Regular rate and rhythm, nl S1/S2, murmurs not appreciated
Abdomen: Obese, nondistended, soft, non-tender, bowel sounds
present. GU: +foley
Ext: warm, well perfused, 2+ pulses. Symmetric 1+ peripheral
edema.
.
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
[**2140-11-18**] 12:00AM BLOOD WBC-9.1# RBC-4.11* Hgb-13.1 Hct-39.6
MCV-96 MCH-31.8 MCHC-33.0 RDW-12.8 Plt Ct-193
[**2140-11-18**] 12:00AM BLOOD Neuts-87* Bands-4 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0 Promyel-1*
[**2140-11-18**] 12:00AM BLOOD Glucose-102* UreaN-16 Creat-1.0 Na-139
K-3.5 Cl-102 HCO3-27 AnGap-14
[**2140-11-19**] 02:00AM BLOOD ALT-33 AST-29 LD(LDH)-197 AlkPhos-74
TotBili-0.9
[**2140-11-18**] 12:00AM BLOOD Calcium-9.1 Phos-1.5* Mg-1.6
[**2140-11-18**] 12:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2140-11-18**] 12:40AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2140-11-18**] 12:40AM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
.
PERTINENT LABS:
[**2140-11-18**] 12:00AM BLOOD proBNP-1718*
[**2140-11-18**] 03:25PM BLOOD proBNP-2526*
[**2140-11-19**] 02:00AM BLOOD proBNP-975*
[**2140-11-18**] 12:00AM BLOOD cTropnT-<0.01
[**2140-11-18**] 05:56AM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-11-20**] 03:07PM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-11-21**] 02:57AM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-11-18**] 12:07AM BLOOD Lactate-3.4*
[**2140-11-18**] 01:34AM BLOOD Lactate-1.8
[**2140-11-19**] 05:35AM BLOOD Lactate-1.3
[**2140-11-20**] 03:15AM BLOOD Lactate-1.2
[**2140-11-19**] 02:00AM BLOOD Fibrino-610*
[**2140-11-19**] 05:16AM BLOOD Ret Aut-1.6
[**2140-11-21**] 02:57AM BLOOD VitB12->[**2128**] Folate-GREATER TH
[**2140-11-19**] 05:16AM BLOOD Hapto-185
.
DISCHARGE LABS:
.
MICRO:
[**2140-11-18**] UCx: no growth
[**2140-11-18**] Urine Legionella Ag: negative
[**2140-11-18**] BCx: no growth to date
[**2140-11-19**] BCx: no growth to date
[**2140-11-20**] BCx: no growth to date
[**2140-11-18**] Influenza A/B: negative
[**2140-11-18**] Sputum Cx: no growth
[**2140-11-19**] Sputum Cx: no growth
.
IMAGING:
[**2140-11-17**] CXR: The heart size is normal. There is a left basilar
opacity and retrocardiac density, concerning for lower lobe
pneumonia or effusion. Linear opacities at the right base likely
reflect atelectasis. The remaining areas of the lungs are clear.
The central pulmonary vessels are prominent. There is no
pneumothorax or large pleural effusion. The left costophrenic
angle is excluded from the study.
.
[**2140-11-19**] TTE: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The patient is
mechanically ventilated. The IVC is small, consistent with an RA
pressure of <10mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded, although there is the suggestion of
possible basal inferior hypokinesis in some views. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size and wall thickness with preserved global
biventricular systolic function. Suggestion of possible basal
inferior hypokinesis in some views, however due to the limited
image quality and patient inability to cooperate while intubated
this cannot be definitively diagnosed. No clinically significant
valvular disease. Indeterminate pulmonary artery systolic
pressure. Compared with the report of the prior study (images
unavailable for review) of [**2134-1-4**], mild mitral regurgitation
is no longer present. The suggestion of possible basal inferior
hypokinesis was not mentioned previously, but suboptimal image
quality was also noted on the prior study and thus may have been
present, but not identified.
.
[**2140-11-21**] CXR: Compared with [**2140-11-20**] at 5:29 a.m. and allowing for
technical differences, there may have been slight improvement in
the degree of opacity in the left mid-zone. Otherwise, no
significant change is detected. Left subclavian central line tip
over mid SVC again noted. Again seen are prominent opacities in
the left mid and lower zone, with retrocardiac air bronchograms
and obscuration of the left costophrenic angle and left
hemidiaphragm. Probable small left effusion. There is also some
patchy perihilar opacity on the right and minimal blunting of
the right costophrenic angle. Doubt CHF.
Brief Hospital Course:
61 year old woman with a history of asthma and OSA who presented
with fevers and SOB secondary to LLL pneumonia complicated by
septic shock requiring pressors and intubation.
.
# Septic shock: Pt developed hypotension in the ED that was
unresponsive to fluids and was thus started on levophed. Lactate
was initially 3.4 which resolved with fluids. Likely source was
her LLL pneumonia and she was empirically started on
azithro/ceftriaxone/vanco. Urine legionella neg, blood cultures
no growth to date, urine culture negative, sputum culture x2
without growth. On hospital day #2 ([**11-20**]) she was weaned of
levophed.
.
# Respiratory failure/Pneumonia: Pt found to have LLL pneumonia
which was treated empirically with vanco/azithro/ceftriaxone
(day 1 = [**11-19**]). Sputum cultures x2 w/o growth. TTE showed no RV
strain and preserved EF, making PE less likely. She was
successfully extubated on [**11-20**] and currently has O2 sats in the
mid-90s on 5L nasal cannula, though does desat to the mid-upper
80s with movement. Vancomycin was discontinued on [**11-21**] and she
was transitioned to oral levofloxacin for completion of an
antibiotic course for community-acquired pneumonia. A total of
14 days of Rx was prescribed given persistence of infiltrate,
oxygen requirement, and dyspnea, as well as concern for a
non-serogroup 1 leigionell infection as pt. had marked
associated n/v with her illness.
# Asthma: Continued home flovent and albuterol and ipratropium
nebs prn. She was treated with a 5-day course of prednisone 40mg
daily ([**Date range (1) 90581**]) for possible asthma flare. The diagnosis of
asthma remains in question. Outpatient pulmonary follow up has
been arranged.
.
# Obstructive sleep apnea: Patient has a diagnosis of OSA but
does not currently wear a CPAP and has not had recent
pulmonology follow up. She occasionally desats to the mid-upper
80s at night which improved upon arousal. Pulmonary follow up
has been arranged, and with RT here in hospital, arranged better
mask fit and resumed use of her CPAP machine with entrained O2
at 3 LPM. Encouraged pt. to use this until follow up and repeat
evaluation with pumonary division as arranged.
.
.
# Nausea/vomiting/diarrhea: Pt reported recent episode of
nausea, vomiting, and diarrhea prior to admission. Legionella
negative for serogroup 1. Had no further episodes with treatment
of pneumonia.
.
# Chest pain: EKG without ischemic changes and cardiac enzymes
negative. Echo showed no focal area of hypokinesis. Chest pain
resoolved and was likely secondary to underlying pneumonia; has
moderate pulmonary hypertension by echo, biwth preserved
systolic and diastolic function.
.
# HTN: Initially held propranolol given septic shock, which was
later restarted.
.
# Depression/Anxiety: Continued fluoxetine and buspirone.
.
# Restless leg syndrome: Continued pramipexole.
.
# GERD: Continued pantoprazole.
Medications on Admission:
1. prozac 60mg daily
2. buspirone 10mg TID
3. ritalin SR 20mg [**Hospital1 **]
4. propranolol 10mg QID
5. pantoprazole 40mg
6. mirapex 1.5mg
7. flnoase 2 sprays qhs
8. glucosamine-condroitin TID
9. fish oil 1000mg TID
10. ibuprofe prn back pain
11. furosemide prn
12. ambien prn
Discharge Medications:
1. oxygen Sig: Three (3) liters per minute Nasal continuous:
3LPM continuous, pulse dose for portability. Use at all times
during day, and connect to cpap at night. Dx: Pneumonia.
Disp:*1 unit* Refills:*1*
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
4. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
5. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Ritalin SR 20 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
7. propranolol 10 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. pramipexole 0.5 mg Tablet Sig: Three (3) Tablet PO daily ().
See comments below in re these medications:
8. glucosamine-condroitin TID - pt. not taking
9. fish oil 1000mg TID - may use if desired
10. ibuprofe prn back pain - encouraged to limit use given
age/htn
11. furosemide prn - pt. not using
12. ambien prn - pt. not using
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Pneumonia
sepsis
asthma exacerbation (possibly) with pulmonary hypertension due
to OSA and hypoxemia requiring oxygen therapy at all times as
above
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent; requires oxygen
therapy at all times as described above, below, and in
prescription
Discharge Instructions:
You were admitted with shortness of breath and fevers found to
have a severe pneumonia that required ICU level of care and
intubation. The infection improved with antibiotics and
hydration. You were also given steroids and inhalers for your
(possible) asthma. Please continue to take the steroids until
you complete the course.
You should also follow up with the pulmonary clinic for
continued management of your sleep apnea (arranged and discussed
with you).
You need to use oxygen at 3 litres per minute at all times (with
cpap at night and portably during the day). A home nurse will
come and see you and check your progress and oxygen levels at
home.
You should use the CPAP machine as we instructed at night, with
the oxygen connected as we instructed and demonstrated to you.
You should consider a trial of allergy medications as you have
endorsed that exposure to your cats may exacerbate your wheezes
- I would recommend claritin or [**Doctor First Name 130**] (over the counter) -
take as instucted on the packaging to see if this helps.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2141-3-2**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2141-4-26**] at 1:10 PM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 486, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4549
} | Medical Text: Admission Date: [**2150-11-30**] Discharge Date: [**2150-12-22**]
Date of Birth: [**2073-10-4**] Sex: M
Service: VSU
The patient was admitted for a evaluation of a right lower
extremity free flap by the plastic CV service. The lower
extremity warranted a vascular evaluation. A right anterior
tibial artery angiogram was obtained for evaluation. There
was noted necrosis at the site of a prior saphenous vein
harvest for a coronary artery bypass graft. Vascular surgery
was consulted with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] who determined
that a right below the knee amputation was needed and the
right below the knee amputation was performed on [**2150-12-7**].
The postoperative course was complicated by respiratory
failure requiring reintubation and transfer to Intensive Care
Unit and also some renal failure for which both the
cardiology service and the renal service were consulted. The
patient's renal failure continued to improve. The
electrophysiology service was consulted regarding an episode
of arrhythmia, the patient with a known automatic implantable
cardiac defibrillator. The patient was evaluated and was
noted to have right ventricle sensing abnormality and
outpatient follow-up was deemed appropriate. The patient
also had a large pleural effusion while he was intubated.
This effusion was drained on [**2150-12-14**], and the patient then
proceeded to self extubate which he was able to tolerate. He
was begun on Coumadin on [**2150-12-16**], and continued on such.
The patient was doing well off the ventilator, had an episode
of emesis on [**2150-12-17**]. The chest x-ray done repeated
showed a new right apical patchy alveolar opacity that was
likely consistent with aspiration. The patient continued to
do relatively well with no need for frequent suctioning for
increased secretions. The patient was transferred to the
Vascular Intensive Care Unit on [**2150-12-17**], and was doing
well. A rehabilitation facility screen was instituted and
the patient continued to do well. On the morning of
[**2150-12-22**], the patient was seen and evaluated and was verbal
about his desire to go to rehabilitation facility. At around
0700 in the a.m. of [**2150-12-22**], the patient was noted to have
no respiratory rate on telemetry and was then evaluated and
found to be unresponsive at the bedside. A code was called
and the patient was noted to have a systolic blood pressure
[**Location (un) 1131**] in the 70s on telemetry but no pulse was noted on
examination. PEA progressing to ventricular fibrillation was
noted, and intermittent direct cardioversion per the
patient's own automatic implantable cardiac defibrillator was
noted. The patient was intubated, no compressions or shocks
were performed as per the patient and family's wishes. ACLS
protocol was instituted and the team was unable to obtain a
pulse throughout despite all the efforts. The patient
expired at 0730 in the morning [**2150-12-22**]. Series of events
were discussed with Dr. [**Last Name (STitle) **], who then proceeded to
contact the family. The medical examiner declined the
postmortem examination. The family agreed to a voluntary
postmortem examination which was to take place as soon as
possible.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17755**], [**MD Number(1) 17756**]
Dictated By:[**Last Name (NamePattern1) 30263**]
MEDQUIST36
D: [**2150-12-22**] 18:44:30
T: [**2150-12-22**] 19:09:07
Job#: [**Job Number 30264**]
cc:[**Last Name (NamePattern4) 30265**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30266**], MD
ICD9 Codes: 5185, 4275, 4280, 5845, 5990, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4550
} | Medical Text: Admission Date: [**2136-6-12**] Discharge Date: [**2136-6-19**]
Date of Birth: [**2062-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left upper lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2136-6-12**]:
1. Left thoracotomy.
2. Partial decortication of lung.
3. Left upper lobectomy.
4. Mediastinal lymphadenectomy.
5. Flexible bronchoscopy.
6. En bloc resection of pericardium.
History of Present Illness:
The patient is a 74-year-old male with a previously treated head
and neck cancer now with an enlarging nodule in the left upper
lobe. Biopsy was
consistent with non-small-cell lung cancer. The tumor was very
close to the inferior pulmonary vein, lower lobe bronchus, and
lower lobe PA and, given this location, we recommended an open
approach.
Past Medical History:
DM
HTN
T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
spiculated nodule in the left upper lobe
PSH:
tracheostomy on [**2134-11-3**]
a PEG tube placed on [**2134-11-17**].
Social History:
He quit smoking three years ago after 150-pack-year history of
smoking. He used to be a teacher in [**Country 5881**] and he came back
himself at the time of consultation.
Family History:
His father was taken to Siberia when the patient was a young
child and he does not know any details of his death or medical
history. His mother died at age 85; perhaps from some sort of
cancer. He has two sisters who are both living, age 75 and 76,
who are reasonably healthy. He has three sons, age 48, 44, and
32.
Physical Exam:
VS: T: 98.2 HR: 70's SR BP: 120/52 Sats: 97% RA
General: 74 year-old male ambulating in halls in no apparent
distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1, S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Incision: left thoracotomy site clean dry intact no erythema.
Lower back with 2 cm x 2 cm area of erythema
Neuro: awake,alert oriented.
Pertinent Results:
Admission labs:
140 106 21 glu 156
3.9 24 0.6
Ca: 8.2 Mg: 1.6 P: 3.9
8.8 > 31.8 < 210
PT: 14.3 PTT: 26.1 INR: 1.2
Brief Hospital Course:
Mr [**Known lastname 84573**] was admitted to the Thoracic Surgery service
immediately following his open left upper lobectomy for a hilar
mass. Please see Dr[**Name (NI) 5067**] operative report for further details.
Of note, estimated blood loss was 500cc and he was transfused
one unit of packed red blood cells. After a brief uneventful
stay in the PACU, he was transferred to the ICU intubated, with
epidural in place and two chest tubes on suction. POD1 in the
ICU he was extubated and continued to remain stable. On POD2 he
was transferred to the floor without issue. He did well the
first night on the floor, but on the morning of POD3 he went
into atrial fibrillation and became hypotensive to SBP in the
low 80's. He was transferred back to the ICU and begun on an
amiodarone drip. He was again transfused 1 unit PRBC while
cardioversion was considered. Cardiology was consulted and
cardioversion was not performed as his blood pressure improved.
He remained in atrial fibrillation most of the day but converted
to sinus rhythm by the evening of POD 3. At this point his
apical chest tube was noted to be draining very little fluid and
did not show an air [**Last Name (LF) 3564**], [**First Name3 (LF) **] that tube was removed. The
following day he was noted to have increased oxygen demand and
chest pain. CT chest revealed a large air/fluid collection in
his left hemi-thorax. A pigtail pleural catheter was placed in
the apex which drained 400cc of serosanguinous (Hct 13) fluid in
the first 24 hours and a significant amount of air. By the
following morning his oxygen requirements were back to baseline
and he remained in sinus rhythm. He was transitioned to oral
amiodarone and returned back to the floor. His epidural and
foley were removed and he was able to void spontaneously by POD
5. His remaining chest tubes were clamped on POD 6 and follow-up
CXR showed no re-accumulation of air or blood.
By the time of discharge on POD7, he was tolerating regular
diet, had his chest tubes removed, voiding spontaneously and
ambulating independently. He was provided discharge instructions
and told to follow-up with Dr [**First Name (STitle) **] as scheduled.
Medications on Admission:
Metformin 500'', Omeprazole 20''
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**First Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical 12 Hours on/12 Hours
off: cut in half and place on either side of chest incision.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
2. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**First Name (STitle) **]: [**5-22**] mL
PO every 4-6 hours as needed for pain.
Disp:*400 mL* Refills:*0*
3. metformin 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Month/Year (2) **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
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. polyethylene glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One
(1) packet PO once a day.
Disp:*30 packet* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left upper lobe lung cancer
Diabetes Mellitus T2
Hypertension
T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Left chest incision develops drainage or increased redness
-Chest tube site removed dressing and cover with a bandaid until
healed
Pain:
-Acetaminophen 650 mg every 8 hours as needed for pain
-Roxicet [**5-22**] mL every 4-6 hours for pain
-Lidoderm patch cut in [**1-15**] on either side of chest
incision.
(DO NOT PUT ON INCISION)
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than 10 pounds until seen
-No driving while taking narcotics
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2136-6-28**] 10:00 on
the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray 4th Radiology 30 minutes before your appointment
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4551
} | Medical Text: Admission Date: [**2142-2-15**] Discharge Date: [**2142-2-22**]
Service: MEDICINE
Allergies:
Tomato / Lorazepam
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 88 yo male with PMH CABG, CHF LVEF 30-35%, metastatic
colon CA who presents with diarrhea and hypotension. He reports
non bloody, yellow diarrhea since [**2-7**], when he was recently
admitted ([**2-7**] to [**2-13**]) for diarrhea thought [**12-20**] chemo meds, c
diff negative, no evidence of colitis on CT. He reports that the
diarrhea had been improving at the time of discharge however, in
the last three days, he has had increasing number of
bowelmovements daily and worsening nausea. He has been unalbe to
tolerate PO x 2days stating that he vomits <30 minutes after a
meal. Yesterday, VNA found him to be weak with BP 94/52
afebrile. The diarrhea continued and he presented to the [**Hospital1 18**]
ED.
.
In the [**Hospital1 18**] ED, intitial VS were: 97.3 86 76/45 20 100% RA. Got
2L IVF, SBP up to 100. EKG with Afib and old Q waves, unchanged
from prior EKG. Labs notable for WBC 3.4, 80%bandemia and
cratinine 3.6 (baseline 1.5-1.7). Given vanc/zosyn, and a total
of 3L IVNS. He had an episode of chest tightnes adn "pressure"
which was different from anginal euqivalant, was given [**Hospital1 **] 325,
2mg IV morphine and pain resolved. EKG unchanged, trop 0.04
which trended to 0.02. CXR showed loss of left heart border and
small left pleural effusion. CT abdomen showed moderately
distended stomach, beyond which oral contrast did not pass
beyond stomach concerning for outlet obstruction. Also with
liver and lung mets which were unchanged. He has been
hemodynamically stable in the ED and was admitted to the ICU for
bandemia, hypotension, [**Last Name (un) **] and possible outlet obstruction.
Admission Vitals: 95([**Last Name (un) 3526**]/[**Last Name (un) 3526**]) 104/50 23 98%.
.
On arrival to the Unit, vitals were 79 100/41 94% 2LNC He
reported mild nausea, hiccups, and chills. Reports breathing
comfortable, denies chest pain, dyspnea. denies abdominal pain,
fever.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Congestive heart failure with previous EF 30% to 35% in [**2140**].
4. Perioperative atrial fibrillation in [**2136**], not on coumadin
now.
5. Basal cell carcinoma.
6. colon cancer dx [**2136**], status post ileocecectomy on [**4-/2137**]
with Dr. [**Last Name (STitle) **]. Mets to liver discovered [**2137**] and now status
post metastatectomy via hepatectomy in 10/[**2137**]. ? Additional
mets discovered [**2139**], s/p cyberknife therapy to liver.
7. Coronary artery disease, status post ST elevation MI in [**2125**]
and three-vessel CABG in [**3-/2128**] (LIMA to the LAD, vein graft to
the first obtuse marginal and to the right PDA)
8. Acute cholecystitis and cholecystectomy in [**2077**].
9. Bladder Cancer [**2139**] followed by Dr. [**Last Name (STitle) 261**]
10. S/p left carotid endarterectomy
Social History:
The patient is a previous mechanical engineer. He smoked
occasionally but quit 35 years ago. He denies any alcohol use.
Lives alone and is independent. No close relatives in the area.
Siblings in [**Location (un) 3156**].
Family History:
Denies family history of cancer, CAD, diabetes.
Physical Exam:
Vitals: T:95.7 BP:100/41 P:79 R:18 O2:99% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Mildly distended, tympanic to percussion ir LUQ, mild
epigastric tenderness. bowel sounds present, no rebound
tenderness or guarding,
GU: foley in place
Ext: 1+ pitting edema to the ankles BL, warm, well perfused.
Pertinent Results:
ADMISSION LABS
[**2142-2-14**] 08:16PM BLOOD Neuts-36* Bands-20* Lymphs-16* Monos-22*
Eos-1 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2142-2-14**] 08:16PM BLOOD WBC-3.4* RBC-2.58* Hgb-8.5* Hct-26.2*
MCV-101* MCH-33.0* MCHC-32.5 RDW-18.2* Plt Ct-119*
[**2142-2-14**] 08:16PM BLOOD PT-15.2* PTT-25.1 INR(PT)-1.3*
[**2142-2-14**] 08:16PM BLOOD Glucose-134* UreaN-44* Creat-3.6*# Na-141
K-3.8 Cl-111* HCO3-17* AnGap-17
[**2142-2-14**] 10:02PM BLOOD Lactate-2.2*
.
CARDAIC ENZYMES
[**2142-2-14**] 08:16PM BLOOD cTropnT-0.04*
[**2142-2-15**] 01:48AM BLOOD cTropnT-0.02*
[**2142-2-15**] 05:43AM BLOOD CK-MB-12* MB Indx-6.5* cTropnT-0.04*
[**2142-2-15**] 03:35PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.03*
.
=======================IMAGING========================
ABDOMINAL PLAIN FILM
FINDINGS:
Supine and lateral decubitus views of the abdomen demonstrate
small amount of residual barium remaining in the stomach. There
are multiple dilated loops of small and large bowel and
air-fluid levels. There is no pneumatosis or free air.
Visualized osseous structures appear intact.
IMPRESSION:
Multiple dilated small and large bowel loops, compatible with
ileus. No
definite evidence of gastric outlet obstruction.
Brief Hospital Course:
An 88 yoM with PMH CABG, CHF LVEF 25-30%, metastatic colon
cancer readmitted with worsening diarrhea.
.
# Hypotension: On arrival to the ED, patient was hypotensive to
76/45, he was mentating well, but was noted to be in acute renal
failure. He was admitted to the ICU where he was resuscitated
with 7L IVNS with stabilization of pressures and good urine
output. Vasoactive medications were not necessary. He was then
called out to the Oncology service for further care.
.
# Diarrhea: Previously attributed to chemotherapy, diarrhea had
been improving until 3 days prior to admission. On admission, he
was afebrile with epigastric tenderness, labs were remarkable
for WBC 3.4 and 20% bands. He was treated with PO Vanco and
metronidazole IV for presumed C. Diff. Stool was negative for
C.diff x 2, so Flagyl and vancomycin were dicontinued. C diff
PCR was negative. WBC count normalized and the patient was
afebrile. Diarrhea was ultimately felt to be [**12-20**] chemotherapy as
all infectious stool studies were negative.
.
# Acute on chronic kidney injury: Creatinine 3.6 on admission up
from baseline of 1.5-1.7. With crystalloid resuscitation,
creatinine trended down to baseline. Acute injury is attributed
to low right sided filling pressures in the setting of poor po
intake and diarrhea.Cr was stable throughout the rest of his
admission.
.
# Ileus: on admission, CT abdomen showed no passage of contrast
beyond pylorus concerning for gastric outlet obstruction. He
reported vomiting x 2days shortly after meals. Repeat abdominal
plain film showed passage of contrast and gas into the large and
small bowel and dialated loops of large and small bowel
consistent with ileus. An NG tube was placed to decompress the
intestine. NGT was removed prior to transfer to the Oncology
floor. His diet was advanced,a dn her was tolerating a regular
diet for several days prior to discharge.
.
# Chronic congestive heart failure with systolic dysfunction:
LVEF 30% to 35% Chest xray from admission shows small pleural
effusions. He had trace peripheral edema but did not appear to
be in acute CHF exacerbation. After aggressive volume
resuscitation, he appeared euvolemic and did not develop acute
CHF. Furosemide had been held in prior admission. The patient
had one episode of SOB on the floor that resolved with IV Lasix.
Otherwise, diuresis was held. In fact, he required a few boluses
of D5W for hypernatremia [**12-20**] intravascular dryness. Pt was
taking good po, and Na was stable for 48 hours prior to
discharge.
.
# Coronary artery disease: Patient with PMH of CABG. Complained
of chest pressure on admission, EKG was unchanged, Trops
negative x 3. Ruled out for myocardial infarction.
.
# A fib: Pt has a history of pAF for which he was previously on
Coumadin. His metoprolol had been stopped on admission. Coumadin
had been stopped [**12-20**] hematemesis. Pt had an episode of AF with
RVR. His rate slowed down with metoprolol, which was titrated to
25mg [**Hospital1 **]; he will be discharged on 50mg metoprolol succinate
qdaily. CHADS2 score 3, so from this standpoint pt should be on
anticoagulation. However, pt has likely months to live from the
standpoint of his malignancy. Discussed risk of stroke vs
benefits of anticoagulation with the patient. He has decided
against Coumadin or Lovenox.
.
# Hypothyroidism: Continued home regimen
.
Pt was full code this admission. Hospice services were brought
up, but the patient was not interested.
Medications on Admission:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-19**]
Puffs Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lovastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed for nausea.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
13. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
14. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
application Topical twice a day as needed for itching.
15. valsartan 80 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. ergocalciferol (vitamin D2) 400 unit Tablet Oral
18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
19. Guaifenesin NR 100 mg/5 mL Liquid Sig: Ten (10) mL PO every
four (4) hours as needed for cough.
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-19**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lovastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day.
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day: hold for HR
< 60, SBP < 100.
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed for nausea.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
13. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical twice a day as needed for itching.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
15. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
16. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO every six (6) hours as needed for pain.
17. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: diarrhea
dheydration
paroxysmal atrial filbrilation
.
Secondary: metastatic colon cancer
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:
Mr. [**Known lastname 10239**],
Thank you for coming to [**Hospital1 69**] for
you care. You were admitted because of dehydration, likely due
to a combination of diarrhea and not eating much. You did not
have an infection causing your diarrhea. We rehydrated you with
IV fluids. You went into an abnormal heart rhythm while you were
here, called atrial fibrilation. We increased your metoprolol to
help slow your heart down. You have had this in the past and
used to be on a medicine called Coumadin to decrease your risk
of stroke. You decided that you did not want to take Coumadin
again.
.
We made the following changes to your medications:
- Please INCREASE metoprolol to 50mg daily
- Please STOP taking valsartan for now. Your doctor may re-start
this medicine if your blood pressure becomes high.
- Please continue to NOT take Lasix.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2142-2-26**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2142-2-26**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 4589, 4019, 2724, 2449, 2768, 2859, 412, 5849, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4552
} | Medical Text: Admission Date: [**2105-8-24**] Discharge Date: [**2105-9-3**]
Date of Birth: [**2042-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Aortic stenosis, Ascending Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2105-8-24**] Bentall Procedure - Aortic Valve Replacement utilizing
a [**Street Address(2) 65560**]. [**Male First Name (un) 923**] mechanical heart vave; Replacement of
Ascending Aorta with 30 millimeter Gelweave Graft with
Reimplantation of Coronary Arteries
History of Present Illness:
Mr. [**Known lastname 107385**] is a pleasant 62 year old male recently diagnosed
with aortic stenosis and ascending aortic aneurysm. His most
recent echocardiogram was from [**2105-6-15**] which showed a marked
dilated aortic root and ascending aorta with moderate to severe
aortic stenosis. His [**Location (un) 109**] was estimated at 0.8 cm2. There was
symmetric LVH and his ejection fraction was estimated at 60-65%.
Cardiac catheterization in [**2105-7-16**] confirmed severe
aortic stenosis and a dilated aortic root, measuring 47
millimeters. Coronary angiography revealed a left dominant
system and mild coronary disease. The LAD had 50% lesions in the
mid and distal segments; the LCX had a mid 30% stenosis; while
the RCA had a 50% proximal stenosis. At the time of admission,
he reports feeling well. He remains active, walking about [**12-18**]
miles several times per week. He denies chest pain, dyspnea,
syncope, presyncope, orthopnea, PND, pedal edema and
palpitations. He will be admitted for cardiac surgical
intervention.
Past Medical History:
As above; Hypertension, Coronary Artery Disease, History of
Atrial Fibrillation, Anxiety, Depression, s/p Appendectomy, s/p
Right Quadricep repair
Social History:
Denies tobacco history. Occasional ETOH. He is single and lives
alone. Works part time as an electrician.
Family History:
Negative for premature CAD
Physical Exam:
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD, no carotid bruits
Lungs: clear bilaterally
Heart: regular rate, s1s2, 3/6 systolic ejectiom murmur radiates
to carotids
Abdomen: soft, NT, ND, normoactive bowel sounds, no pulsatile
masses
Ext: warm, no edema
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2105-9-2**] 06:40AM BLOOD WBC-6.5 RBC-3.08* Hgb-9.0* Hct-25.8*
MCV-84 MCH-29.0 MCHC-34.7 RDW-13.4 Plt Ct-389
[**2105-9-3**] 05:47AM BLOOD PT-20.1* INR(PT)-2.9
[**2105-8-30**] 04:20AM BLOOD Glucose-95 UreaN-20 Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
[**2105-9-1**] 06:05AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2105-9-1**] 06:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
Brief Hospital Course:
Pt. was a same day admit and was brought directly to the
operating room where he underwent a Bentall procedure. Surgery
was uneventful with total bypass time of 123 minutes,
cross-clamp time of 74 minutes, and circ. arrest time of 9
minutes. Please see op note for surgical details. Pt was
transferred to the CSRU in stable condition on Epinephrine and
Propofol gtts. Later on op day pt was weaned from mechanical
ventilation and sedation and was extubated. He was
neurologically intact. He was weaned off of Epinephrine and
transferred to the telemetry floor on POD #1. Diuretic and
B-blockers were started per protocol. Chest tubes and epicardial
pacing wires were removed on POD #2. Coumadin was also initiated
on this day and was titrated throughout his hospital course for
a goal INR between 2.5 and 3 (mechanical valve). On HD #3 pt's
heart rhythm went into Atrial Flutter. He was started on
Amiodarone and Lopressor was increased. On POD #5 pt was
initially noticed to have erythema at old right hand/wrist IV
site. Pt. had a temperature over 102 on POD #7 with continued
erythema/warmth on right hand (phlebitis/cellulitis). Pt. was
already receiving Ancef which was eventually changed to
Vancomycin. RUE U/S on [**9-1**] revealed cellulitis w/ a 1x2cm
collection deep to the focal raised lesion, no DVT. Vascular
surgery was consulted and drained (irrigation and debridement)
abscess on POD #7. Cultures of purulent drainage sent (please
see final report). Blood cultures negative. On POD #9 pt had
PICC line placed for continuing IV ABX (cont. for 10 days). Back
on POD #6 pt had to have Foley reinserted for Urinary retention.
He was started on Flomax and Foley was eventually removed. He
was followed throughout his entire post-op course by physical
therapy and treated accordingly. Aside from the Atrial Flutter
and right hand phlebitis pt recovered well post-operatively and
was discharged on POD #10. His INR at time of discharge was 2.9.
Dr. [**Last Name (STitle) 3649**] will be following his INR/Coumadin. His labs were
stable and exam unimpressive at time of discharge. He was
discharged home with VNA services and appropriate follow-up
appointments.
Medications on Admission:
Accupril, Ativan, Aspirin - patient unaware of dose
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. 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*
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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Accupril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400 mg PO daily for 7 days, then decrease to 200 mg PO daily.
Disp:*60 Tablet(s)* Refills:*0*
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 10 days.
Disp:*20 g* Refills:*0*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
14. Coumadin 5 mg Tablet Sig: 1 tablet alt. with 1.5 tablet
Tablet PO at bedtime: 5 mg alternating with 7.5 mg.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**] - east
Discharge Diagnosis:
Aortic stenosis/Ascending aortic aneurysm s/p Bentall Procedure
- Aortic Valve Replacement with [**Street Address(2) 65560**]. [**Male First Name (un) 923**]
mechanical heart vave & Replacement of Ascending Aorta with 30
millimeter Gelweave Graft with Reimplantation of Coronary
Arteries
Coronary Artery Disease
Hypertension
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.
Do not use lotions, powders, or creams on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with [**Doctor Last Name 3649**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 5293**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make and appointment with Dr. [**Last Name (STitle) 1391**] (Vascular Surgery) for 2
weeks
Completed by:[**2105-10-1**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4553
} | Medical Text: Admission Date: [**2151-10-13**] Discharge Date: [**2151-10-15**]
Date of Birth: [**2086-8-10**] Sex: M
Service: MEDICINE
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with balloon angioplasty of a previously
placed drug eluting stent.
History of Present Illness:
65 year old Male with a history of HTN, HL, CAD s/p NSTEMI with
DES placed to LAD in [**2150-1-6**], who presented with chest pain
since 9 am this morning. Patient was driving to doctor's
appointment and experienced diaphoresis, heart burn then left
sided chest discomfort. Per wife patient "passed out" for a
couple of minutes. Patient asked for help at [**Hospital Ward Name 23**] Center and
was consequently sent to ED. Patient denies nausea or shortness
of breath.
.
Of note, patient has been taking ASA consistently, even during
knee surgery and melanoma excision over the past year. He
stopped his plavix in [**Month (only) 956**] per recommendation of his
cardiologist.
.
In ED, initial vitals were 97, HR 78, bp 100/85, rr 18, o2 sat
98% nrb. In ED patient received Plavix 600 mg load, Heparin
bolus, Integrillin bolus and morphine. EKG demonstrated
anterior/lateral STE. Patient was taken to cath lab which
demonstrated in stent thrombus of LAD. Mechanical aspiration,
thrombectomy, and angioplasty were performed. Patient was
hemodynamically stable and admitted to CCU for further
monitoring.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI in [**2150-1-6**] s/p
stent to LAD
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
1. Hodgkin's lymphoma treated in [**2128**] at [**Hospital6 1130**] with radiation therapy to his mediastinum, and
chemotherapy. He is also status post splenectomy during the
staging workup for his disease.
2. R plantar invasive melanoma s/p excision, R femoral sentinel
lymph node biopsy, with split-thickness skin graft on [**2151-10-7**]
3. Coronary artery disease status post non-ST elevation MI
followed by an LAD stent in [**2150-1-6**].
4. Status post left knee surgery in [**2151-5-7**].
5. Status post left shoulder surgery x2 once for a rotator cuff
repair and second time for labral repair.
6. Herniorrhaphy for ventral hernia in [**2142**].
Social History:
He owns and operates an auto/truck body shop
with his son. [**Name (NI) **] is married and lives with his wife of 37 years.
They have 3 children. He is a lifetime nonsmoker. He rarely
drinks alcohol and states he drinks perhaps 1 time per month.
Family History:
His father died at age 55 from complications of
sarcoma. His mother died at age 62 from leukemia. He has a
69-year-old brother who is alive and well. He has no family
history of melanoma.
Physical Exam:
VS: T=36.4 BP=116/64 HR=77 RR=14 O2 sat=95%
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2151-10-13**] 10:03AM PT-11.5 PTT-22.7 INR(PT)-1.0
[**2151-10-13**] 10:03AM PLT COUNT-396
[**2151-10-13**] 10:03AM NEUTS-66.3 LYMPHS-26.4 MONOS-4.9 EOS-1.8
BASOS-0.5
[**2151-10-13**] 10:03AM WBC-12.8* RBC-4.68 HGB-14.4 HCT-42.2 MCV-90
MCH-30.8 MCHC-34.1 RDW-14.8
[**2151-10-13**] 10:03AM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.3
[**2151-10-13**] 10:03AM CK-MB-3
[**2151-10-13**] 10:03AM cTropnT-<0.01
[**2151-10-13**] 10:03AM CK(CPK)-116
[**2151-10-13**] 10:03AM GLUCOSE-169* UREA N-18 CREAT-1.4* SODIUM-135
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
[**2151-10-13**] 06:17PM PLT COUNT-364
[**2151-10-13**] 06:17PM WBC-14.9* RBC-4.32* HGB-13.0* HCT-39.5*
MCV-91 MCH-30.1 MCHC-32.9 RDW-14.5
[**2151-10-13**] 06:17PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2151-10-13**] 06:17PM CK-MB-73* MB INDX-7.4* cTropnT-2.00*
[**2151-10-13**] 06:17PM CK(CPK)-993*
Cardiac Cath [**10-13**]
COMMENTS:
1. Selective coronary angiography of this left dominant system
demonstrated one vessel CAD. The LMCA, LCX and nondominant RCA
was
without significant angiographic disease. The LAD had a 95% in
stent
occlusion with extensive thrombus.
2. Right heart catheterization post-intervention demonstrated
mild
systemic arterial hypotension (95/50 mmHg) with normal pulmonary
arterial pressures (31/14/23 mmHg) and mildly elevated right and
left
sided filling pressures (mean RAP 11 mmHg, RVEDP 13mmHg, mean
PCWP
13mmHg). Cardiac index was preserved at 3.5L/min/m2. Left
ventriculography was deferred.
3. Successful manual and mechanical aspiration thrombectomy and
PTCA
were performed in the mid-LAD. Intravascular ultrasound showed
good
expansion of the prior stent without areas of flow-limiting
stenoses.
Final angiography showed normal flow, no apparent dissection,
and a 10%
residual stenosis. (See PTCA comments.)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. ST elevation myocardial infarction.
3. Thrombectomy and PTCA of the mid-LAD.
4. Preserved cardiac index.
TTE [**10-14**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). However, there is focal hypokinesis of the
midventricular segment of the anterior septum. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The left ventricular inflow
pattern suggests impaired relaxation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2150-3-10**], left ventricular function remains preserved.
Brief Hospital Course:
65 year old M p/w anterior STEMI found to have re-stent thrombus
of mid LAD.
.
# CORONARIES: Anterior STEMI found to have re-stent thrombus of
mid LAD s/p PTCA. Patient's Metoprolol dose was increased, and
patient was discharged on ASA, simvastatin, Metoprolol,
Valsartan, and Plavix [**Hospital1 **] for 2 months, then daily for life.
Cardiac enzymes peaked at CK 73* CkMB 7.4* Trop 2.00* then
down-trended.
.
# PUMP: Echo from [**2150-3-7**], shows normal EF. TTE [**10-14**] showed
EF 70% with midventricular hypokinesis of anterior septum.
Patient was euvolemic in-house, continued on Metoprolol at
increased dose, as above.
.
# Elevated Cr: Cr 1.4 on admission, improved to 0.9. Most
likely hypoperfusion in the setting of ISRS.
.
# R plantar melanoma s/p excision and LN biopsy: General surgery
consulted in the ED, followed patient during his stay. LN biopsy
negative, communicated to patient by surgery team. Wound
dressing changed, f/u appointment with Dr. [**Last Name (STitle) 519**] as an
outpatient.
.
# s/p splenectomy: Patient prescribed one month of Bactrim
starting [**10-5**] for prostatitis. Continued abx in-house.
Medications on Admission:
Metoprolol XR 25 mg po daily
Nitroglycerin 0.4 mg SL PRN CP
Simvastatin 40 mg po daily
Tamsulosin [Flomax] 0.4 mg po qhs
Trimethoprim-Sulfamethoxazole 800 mg-160 mg Tablet
1 Tablet(s) by mouth [**Hospital1 **] x 30 days [**2151-10-5**]
Valsartan [Diovan] 80 mg po daily
Aspirin 325 mg po daily
Omega-3 Fatty Acids [Fish Oil]
Discharge Medications:
1. Wheelchair Device Sig: One (1) Miscellaneous once a day:
Wheelchair with elevated leg rests.
Disp:*1 device* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*11*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-3 tablets
Sublingual every 5 mintues x3 [**Year (4 digits) 4319**] only: call 911 if you still
have chest pain after 3 nitroglycerin tablets.
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertension
Hyperlipidemia
Plantar melanoma
Discharge Condition:
stable.
Discharge Instructions:
You had a heart attack because the stent clotted off. Your heart
pumping function continues to be normal despite the heart
attack. You will be on Plavix twice daily for 2 months and then
daily therafter. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix
unless your cardiologist tells you to. You should also take a
full 325mg aspirin every day for the rest of your life. You will
need to follow up with Dr. [**Last Name (STitle) **].
.
Medication changes:
1. We increased your Metoprolol Succinate (long acting version)
to 50 mg daily
2. Plavix increased to twice daily for at least two months
3. Increase Simvastatin to 80 mg daily
.
Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble
breathing, nausea, fatigue or dizziness, severe headache, dark
stools or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] on [**2151-10-20**] at 1:45PM in his
clinic. ([**Telephone/Fax (1) 22135**].
Primary Care:
[**Last Name (LF) 10531**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 9347**] Date/Time:
Urology:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-10-30**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2151-11-30**] 8:15
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2151-11-10**] at
11:40am.
ICD9 Codes: 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4554
} | Medical Text: Admission Date: [**2119-12-20**] Discharge Date: [**2120-1-2**]
Date of Birth: [**2071-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with common bile duct stent placement
Mechanical ventilation
PICC placement
History of Present Illness:
Admission Date/Time:[**2119-12-20**]
CC: Abdominal pain
HPI: 48M with history of alcohol-induced pancreatitis who
presented to [**Hospital6 19155**] on [**12-15**] with abdominal
pain consistant with prior episodes. Patient was still drinking
alcohol. On admission, lipase was 713, along with elevated
AST/ALT. CT showed evidence of pancreatitis along with
pancreatic duct dilation and an enlarged common bile duct. His
labs were improving with LFT's including lipase were falling,
however his bilirubin was rising from 2.7 to 9.9. His pain
continued to worsen. MRCP was then performed that showed large
heterogeneous head of the pancreas most likely secondary to
pancreatitis, likely choledochocyst, and pancreatic pseudocyst
or less likely dillated Wirsung duct with pancreatitc divisum.
In addition prior to transfer after approx 48 hrs in the
hospital the patient began to get tremulous and agitated and he
was suspected to be in etoh w/d and was placed on CIWA and
required restraints.
At the time of admission the patient is still quite confused,
attempting to punch staff and requiring restraints.
ROS:
On ROS the patient denies any symptoms including abd pain.
Past Medical History:
etoh pancreatitis
asthma
right eye blindness
history of pneumonitis in the past
L5 disk surgery
Social History:
Patient states he drinks 2 bottles of wine a day. Currently
married for 21 months. Denies any drug use and is a current
smoker. Currently working as a manager at [**Company 85858**] Sporting Goods
in [**Hospital1 3597**], NH. Has 2 children
Family History:
mother died of colon cancer at 66 an father died of brain
aneurysm at 57. He has 1 brother who is alive and 5 sisters who
have no medical problems(one died in [**Name (NI) 8751**]).
Physical Exam:
VS: 97.2 154/98 78 26 97Ra
Gen: tremulous, but falling asleep during the exam. AAO x 1, but
answering some questions
Skin: warm to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice, OP clear .
blind in right eye.
CV: RRR no audible m/r/g
Lungs: clear to auscultation
Abd: soft, tender in epigastrim to deep palpation only, normal
BS
Ext: No C/C/E
Neuro: not complaint with neuro exam
Pertinent Results:
Labs on admission:
[**2119-12-20**] 09:05PM WBC-9.4 RBC-4.12* HGB-14.2 HCT-41.1 MCV-100*
MCH-34.4* MCHC-34.6 RDW-13.6
[**2119-12-20**] 09:05PM NEUTS-86.6* LYMPHS-7.2* MONOS-5.6 EOS-0.5
BASOS-0.1
[**2119-12-20**] 09:05PM PLT COUNT-185
[**2119-12-20**] 09:05PM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-134
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-13
[**2119-12-20**] 09:05PM CALCIUM-8.5 MAGNESIUM-1.5*
[**2119-12-20**] 09:05PM ALT(SGPT)-307* AST(SGOT)-244* ALK PHOS-68
AMYLASE-83 TOT BILI-11.2* DIR BILI-8.1* INDIR BIL-3.1
[**2119-12-20**] 09:05PM LIPASE-116*
[**2119-12-20**] 09:05PM PT-17.1* PTT-29.7 INR(PT)-1.5*
.
Labs on discharge:
[**2120-1-1**] 06:00AM BLOOD WBC-9.4 RBC-3.77* Hgb-12.6* Hct-36.8*
MCV-98 MCH-33.4* MCHC-34.3 RDW-13.2 Plt Ct-409
[**2119-12-30**] 05:32AM BLOOD PT-13.8* PTT-33.2 INR(PT)-1.2*
[**2120-1-2**] 05:34AM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-134
K-3.9 Cl-99 HCO3-28 AnGap-11
[**2120-1-2**] 05:34AM BLOOD ALT-62* AST-31 AlkPhos-142* TotBili-2.2*
[**2120-1-1**] 06:00AM BLOOD Lipase-220*
[**2120-1-2**] 05:34AM BLOOD Calcium-9.0 Phos-5.2* Mg-1.8
[**2119-12-30**] 05:32AM BLOOD calTIBC-308 Ferritn-303 TRF-237
[**2119-12-29**] 05:34AM BLOOD VitB12-984* Folate-10.7
[**2119-12-29**] 05:34AM BLOOD TSH-2.7
[**2119-12-29**] 05:34AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2119-12-30**] 05:32AM BLOOD AMA-NEGATIVE Smooth-POSITIVE
[**2119-12-30**] 05:32AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2119-12-29**] 05:34AM BLOOD HCV Ab-NEGATIVE
.
OSH imaging:
CT abd [**12-15**]
CBD(1.7cm) and pancreatitic duct(1.1 cm) dilatation and
edematous changes in the head of the pancreas and in the 2nd
portion of the duodenum with mass effect.
.
MRI [**12-19**]
enlarged heterogenous head of the pancreas most likely due to
pancreatitis, although a pancreatiic neoplasm cannot be
excluded. Also a likely choledochal cyst. right poleural
effusion with possible infiltrate in RLL.
.
[**Hospital1 18**] imaging:
ERCP [**12-21**]
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Mucosa: Severe diffuse congestion and erythema of the mucosa
with contact bleeding were noted in the duodenal bulb and second
part of the duodenum.
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification. The
procedure was moderately difficult.
Biliary Tree: A single smooth stricture that was 20 mm long was
seen at the lower third of the common bile duct. There was
moderate post-obstructive dilation. The rest of the biliary tree
was normal.
Procedures: A 7cm by 10mm Cotton-[**Doctor Last Name **] biliary stent was placed
successfully in the lower third of the common bile duct using a
Oasis system stent introducer kit.
Impression: Severe edema and inflammation of the duodenum,
consistent with pancreatitis. (cannulation)
Biliary stricture was noted in the lower third of the CBD,
otherwise normal biliary tree.
A biliary stent was placed.
.
Non-contrast chest CT [**2119-12-24**]
FINDINGS:
Moderate right and small left pleural effusions, both of which
measure simple fluid in attenuation. They appear to layer
dependently, with no evidence for loculation based on
morphology. There is no pneumothorax. In the right lung, there
is dense consolidation of the lower and middle lobe, with
complete opacification of the lung parenchyma and multiple air
bronchograms. In the right upper lobe, there are additional
patchy ground-glass opacities with associated bronchial wall
thickening. Similar patchy ground-glass opacities are seen
throughout the left lung, most prominent in the lower lobe and
lingula, with relative sparing of the left upper lobe. There is
again bronchial wall thickening. Superimposed interstitial
thickening suggests a component of volume overload. There are no
definite nodules or masses, although evaluation for small
lesions is limited given the underlying consolidation and low
volumes.
IMPRESSION:
1. Moderate right and small left pleural effusions, simple fluid
attenuation.
2. Dense opacification of the right lower and middle lobes, with
air bronchograms. Additional patchy opacities throughout the
right upper lobe, and left lung, predominantly in the lower lobe
and lingula, compatible with multifocal pneumonia. There is
associated bronchial wall thickening, and narrowing of the right
main stem and lower lobe bronchi, as desctibed above.
3. Interstitial thickening compatible with volume overload.
4. Cardiomegaly.
5. Anterior pararenal spacefat stranding, compatible with
history of pancreatitis. Though evaluation is limited without
intravenous contrast, there is also suggestion of pancreatic
ductal dilatation in the visualized body and tail of the
pancreas.
.
Right upper extremity ultrasound [**2119-12-26**]:
Complete thrombosis of the right cephalic vein, however, no
evidence of
deep vein thrombosis of the right upper extremity.
.
Non-contrast head CT [**2119-12-28**]:
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, hydrocephalus, major or minor
vascular territorial infarction. The density values of the brain
parenchyma are maintained. The sulci are slightly prominent for
the stated age. A tiny focal calcification is noted within the
pons. The soft tissues and osseous structures are unremarkable.
A small mucus retention cyst is noted within the left maxillary
sinus. Otherwise, the visualized paranasal sinuses and mastoid
air cells are clear. Dense vascular calcifications are noted of
the cavernous portions of the carotid arteries.
IMPRESSION:
1. No acute intracranial hemorrhage or other intracranial
process.
2. Calcifications involving the cavernous internal carotid
arteries.
3. Mild cerebral atrophy.
4. Focal calcification in the pons of uncertain etiology.
.
Liver/Gallbladder US [**2119-12-29**]:
FINDINGS:
The liver appears normal in echotexture without focal masses or
lesions. There is no intrahepatic biliary ductal dilation. The
CHD measures 2.4 mm. The CBD, however, contains a stent and is
dilated up to 1 cm. The stent extends into the pancreatic duct,
which also appears dilated. The pancreatic parenchyma appears
unremarkable. There is no abdominal ascites. The spleen appears
normal in echotexture measuring 11.5 cm. There is a small amount
of pleural fluid.
IMPRESSION:
Biliary stent in place with a dilated CBD to 1 cm. No
intrahepatic biliary ductal dilation. Trace pleural fluid, but
no ascites.
.
Left upper extremity ultrasound [**2119-12-29**]:
IMPRESSIONS: The left basilic PICC in place. No left upper
extremity DVT, nor thrombosis of the left basilic vein seen.
Brief Hospital Course:
48M with a history of recurrent alcoholic pancreatitis admitted
for ERCP with common bile duct stricture, now s/p CBD stent
placement. Hospital course complicated by ICU stay for hypoxic
respiratory failure, hospital-acquired pneumonia, alcohol
withdrawal, right upper extremity superficial vein thrombus, and
altered mental status.
.
# Common bile duct stricture: Patient had increasing direct
hyperbilirubinemia at outside hospital despite falling AST, ALT,
and lipase. ERCP here revealed a CBD stricture, which was
stented. His total bilirubin trended down following this
intervention but increased slightly after a trial of clears.
Abdominal ultrasound showed no stent obstruction. Patient was
started on ursodiol to treat possible biliary sludge. His
bilirubin trended down to 2.2 on discharge, with patient
tolerating full diet. He has been instructed to continue taking
ursodiol and will have his stent removed by ERCP on [**2120-2-15**].
.
# Acute alcoholic pancreatitis: Lipase had been improving with
IV fluids on the floor, then increased transiently with ERCP.
His lipase gradually trended down with a slight bump concurrent
with his initial trial of clears, thought to be due to biliary
sludge or exacerbation of his underlying pancreatitis. At
discharge, his lipase had trended down to 220. The patient
remained asymptomatic without abdominal pain, nausea, or
vomiting.
.
# Hospital-acquired pneumonia: Initially, patient was intubated
for ERCP and remained intubated afterwards for agitation from
alcohol withdrawal. However, he subsequently failed extubation
due to purulent copious secretions and aspirated. He was
initially treated with vancomycin and cefepime. Chest imaging
was consistent with right-sided pneumonia, possibly with an
aspiration component, as well as ipsilateral pleural effusion.
Sputum cx grew Strep pneumo. In this setting, patient developed
increased white count from his leukopenic baseline. There was
concern for parapneumonic effusion vs. empyema. Abx were
tailored to vancomycin and ceftriaxone. Chest CT showed
multifocal PNA with right greater than left sided pleural
effusions. Bedside thoracentesis on the right was done [**12-24**],
with drainage of 300 cc serous fluid that was significant for
uncomplicated parapneumonic effusions. Patient was extubated
[**2119-12-26**] without any complications and called out to the floor
on [**2119-12-27**]. Vancomycin and ceftriaxone were discontinued on
the floor given that the patient had completed a full course for
HAP and he has improved breathing and pulmonary exam.
.
# Alcohol withdrawal/ Alcohol abuse: . Pt was increasingly
tachycardic, agitated, and tremuluous on the floor, where he was
receiving lorazepam by CIWA scale. He was initially maintained
in the [**Hospital Unit Name 153**] on a propofol gtt, but was changed to fent/versed
which were weaned off for extubation. He received
MVI/Folate/Thiamine. Patient was seen by social work during
admission and appeared motivated to seek additional inpatient or
outpatient rehab. He has been given a list of rehab facilities
to call for availability
.
# Altered mental status: Pt was confused and sometimes agitated
during his ICU stay. His altered mental status was thought to
be multifactorial, likely [**12-26**] ICU psychosis and possible hepatic
encephalopathy. Correctable causes of altered mental status
were ruled out with normal B12, TSH, and RPR. A head CT showed
no acute intracranial processes. Patient was started on
lactulose and rifaximin to treat possible hepatic encephlopathy,
and patient became increasingly attentive and oriented. He was
instructed to continue lactulose (titrated to 3 BM/day) and
rifaximin on discharge and will follow up with Hepatology.
.
# Hepatitis: Pt had persistently elevated LFTs as well as
hepatomegaly, low albumin, and elevated INR on admission, which
were thought to be due in part to alcoholic liver disease in the
setting of acute pancreatitis/CBD obstruction. Hepatology was
consulted on the patient. A diagnostic work-up for other
etiologies of hepatitis were negative, including negative HBV
and HCV serologies, normal iron studies (transferrin, ferritin,
TIBC), negative anti-mitochondrial antibody, negative [**Doctor First Name **],
slightly positive anti-smooth muscle antibody (1:20).
Alpha1-antitrypsin and ceruloplasmin levels were pending at
discharge. His INR trended down with vitamin K. Abdominal
ultrasound showed normal liver without ascites. He is scheduled
for outpatient follow-up with Hepatology.
.
# Right upper extremity superficial vein thrombus: Patient
developed a thrombus in his right cephalic vein in the setting
of an indwelling PICC. The PICC was removed and patient was
treated with Lovenox for one week.
.
# Tobacco abuse: Patient was placed on a nicotine patch during
admission and was instructed to continue on discharge. Smoking
cessation was performed.
Medications on Admission:
Medications on transfer:
MVI/folate/thiamine
Dilaudid
Nicotine patch
Valium CIWA
B12
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
7. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)): In addition to 2 tablets twice a day.
Disp:*30 Tablet(s)* Refills:*2*
9. 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
Discharge Diagnosis:
Primary diagnosis:
Common bile duct obstruction causing hepatitis
Alcohol induced pancreatitis
Hospital Acquired Pneumonia causing acute respiratory failure
Catheter associated DVT
Delirium
Alcohol withdrawal
Hepatic Encephalopathy
Tobacco and alcohol abuse
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] for alcohol-induced pancreatitis and
obstruction of your bile duct. You had a procedure to place a
stent in your bile duct and your pancreatitis improved. You
also had alcohol withdrawal and were admitted to the intensive
care unit. In the ICU, you had pneumonia, which we treated with
antibiotics. You also had a blood clot in your right arm, which
we treated with blood thinners. You were found to have
alcohol-related liver disease with confusion. You were given
medications to clear your confusion.
.
You should abstain from alcohol. You should eat low-fat meals
with vitamin supplements.
.
You should also continue taking your medications for confusion
and liver disease as follows ...
START Lactulose 30mg three times a day (if you develop freq
loose stools, cut back your dose to have 3 bowel movements per
day)
START Rifaxamin 400mg three times a day
START Pantoprazole 40mg once a day
START Ursodiol 500mg twice a day plus 250mg at night
START Multivitamin, Thiamine, and Folic acid daily
START Nicotine Patch - abstain from smoking
Followup Instructions:
Please keep the following appointments:
Appointment #1
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Tuesday, [**1-16**] @ 10:30am
Location: [**Location (un) 85859**], [**Location (un) 11333**]***
Phone number: [**Telephone/Fax (1) 85860**]
Special instructions for patient: ***Patient needs to be aware
that Dr. [**Last Name (STitle) **] moved her office 2 weeks ago to the new address
above address above
.
Appointment #2
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: GI/ ERCP
Date/ Time: Thursday, [**2-15**] @12 noon for procedure, patient
needs to be there for 11am arrival
Location: [**Hospital Ward Name 1950**] 4, Endoscopy suite
Phone number: [**Telephone/Fax (1) 463**]
Special instructions for patient:
.
Appointment #3
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
Specialty: Hepatology/Liver Center
Date/ Time: Wednesday, [**2-8**] @ 3:20pm
Location: [**Hospital Ward Name 517**],[**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Office Medical
Building , Suite 8E
Phone number: [**Telephone/Fax (1) 2422**]
Special instructions for patient:
Completed by:[**2120-1-3**]
ICD9 Codes: 5070, 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4555
} | Medical Text: Admission Date: [**2160-4-17**] Discharge Date: [**2160-4-19**]
Date of Birth: [**2100-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
AMS, hypoglycemia
Major Surgical or Invasive Procedure:
extubated here (intubated at OSH)
History of Present Illness:
59 yo man with IDDM, EtOH cirrhosis transferred from
[**Hospital1 **] ED here for management of AMS. Per EMS notes,
family reported pt became agitated and went into room. They went
to check on him and found him unresponsive with cyanotic head,
neck, and face. When EMS arrived, FSG was 29. Pt was placed on
15L O2. Pulse was not appreciated and pt thought to have agonal
breathing, so CPR was done for "PEA arrest" while IV fluids
started. After a minute of CPR, pulse was found. Pt given 1 amp
D50 with repeat FSG 145 and improved MS. EKG was NSR @ 70 bpm.
He was brought to the [**Hospital1 **] ED where FSG was 158. He
was reportedly conversant on arrival and following commands but
thought to have "agonal breathing" so was intubated. EKG read as
junctional rhythm. CT head negative for acute intracranial
changes. The pt was transferred here for further management.
.
In the ED, initial VS were: Afebrile, P 75, 143/69 RR 20, O2sat
100% on PS, FSG 105. Intubated but awake & following commands.
2->1 pupils. BS ok. 1+ b/l pitting edema. EKG without ischemic
changes, prolonged PR. CXR showed ETT in good position. Ammonia
pending. VS on transfer: T 98.3, P 92, BP 119/71, RR 20, O2sat
100% on PS 10/5, FiO2 40%.
.
On the floor, pt has been extubated. Complains only of sore
throat [**2-5**] intubation. He cannot recall the evening's events but
recalls being in his USOH prior. He has had widely fluctuant FSG
recently with AM FSG as low as 40s; this AM was in 70s and
asymptomatic. He reports normal meals; no N/V/D; no
F/C/CP/cough/SOB/dysuria. He was admitted to [**Location (un) 1459**] [**Hospital1 107**]
1 month ago for similar episode of AMS in the setting of
hypoglycemia and presumed hepatic encephalopathy.
.
Review of systems:
As above, otherwise negative.
Past Medical History:
Hypertension
Hyperlipidemia
Type 2 DM c/b nephropathy and diabetic neuropathy
EtOH cirrhosis without varices on [**11-10**] EGD
Anemia thought due to EtOH BM suppression per pt
OSA
Obesity
B/l knee osteoarthritis
S/p left knee meniscus repair in [**2152**]
S/p bilateral cataract surgery
Social History:
Does computer sales from home. Lives with wife and mother. [**Name (NI) **]
1 son and 1 daughter.
- Tobacco: Denies
- Alcohol: H/o [**1-7**] scotch on weekends x 25 years, then [**1-7**]
scotch daily x 1 year until [**4-11**], abstinent since.
- Illicits: Denies.
Family History:
Father with alcoholic cirrhosis, died of "thoracic aneurysm."
Uncle with diabetes.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: +Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema at ankles b/l
Neuro: AAO x 3, CN II-XII intact, strength 5/5, sensation to LT
intact, cerebellar fxn nl, no pronator drift, +mild tremor,
reflexes symmetric, toes downgoing on Babinski, gait not
assessed.
Pertinent Results:
[**2160-4-18**] 03:49AM BLOOD WBC-8.3# RBC-4.50* Hgb-12.9* Hct-38.3*
MCV-85 MCH-28.8 MCHC-33.8 RDW-17.6* Plt Ct-97*
[**2160-4-18**] 03:49AM BLOOD Neuts-80.4* Lymphs-10.6* Monos-7.9
Eos-0.6 Baso-0.5
[**2160-4-18**] 03:49AM BLOOD Plt Ct-97*
[**2160-4-18**] 03:49AM BLOOD PT-14.8* PTT-32.3 INR(PT)-1.3*
[**2160-4-18**] 12:45AM BLOOD Glucose-93 UreaN-29* Creat-1.9*# Na-144
K-4.2 Cl-110* HCO3-22 AnGap-16
[**2160-4-18**] 12:45AM BLOOD ALT-35 AST-82* AlkPhos-83 TotBili-1.4
[**2160-4-18**] 03:49AM BLOOD CK(CPK)-432*
[**2160-4-18**] 03:47PM BLOOD CK(CPK)-301
[**2160-4-18**] 03:49AM BLOOD CK-MB-10 MB Indx-2.3 cTropnT-0.07*
[**2160-4-18**] 03:47PM BLOOD CK-MB-6 cTropnT-0.05*
[**2160-4-19**] 07:35AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
[**2160-4-18**] 12:15AM BLOOD Ammonia-65*
[**2160-4-18**] 12:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
cxr [**4-17**]: IMPRESSION:
1. Adequate endotracheal tube position.
2. Cardiomegaly, with central vascular congestion suggesting
volume
overload/decompensation.
Brief Hospital Course:
59 yo man with h/o IDDM, alcoholic cirrhosis p/w AMS, found to
be hypoglycemic with report of PEA arrest and intubation for
airway protection admitted to the medical ICU for further
management.
.
# Hypoglycemia: He has a history of labile blood sugars and was
found to be symptomatically hypoglycemic requiring EMS. During
his hospitalization his sugars were closely monitored. [**Last Name (un) **]
diabetes service was consulted regarding insulin management. He
was restarted on a reduced dose of levemir and a modified
insulin sliding scale as well as symlin.
-Pt asked to make f/u with his endocrinologist asap
.
# Altered mental status: He was found to be confused in the
setting of hypoglycemia that rapidly corrected with return to
normoglycemia. CT head at the outside hospital was negative for
intracranial bleed. At [**Hospital1 18**], the patient was at baseline mental
status with a non-focal neurological exam.
.
# Questionable PEA arrest: Pt returned to hemodynamic stability
with less than one minute of chest compressions in the field.
Given his low blood sugar in the field and the rapidity with
which he recovered, it is not clear that he had a true cardiac
arrest. He had EKGs from OSH which showed a junctional rhythm
with occasional PACs. At [**Hospital1 18**], pt was in NSR. He was monitored
on telemetry without event. Pt was also intubated in the field,
extubated on admission to [**Hospital1 18**].
# Chronic renal failure: He was found to have an elevated
creatinine of 1.9, with recent baseline of 1.7. Medications
were renally dosed. Nephrotoxic medications were held. Pt
already had f/u arranged with his nephrologist for 3days
post-discharge.
.
# Anemia: Pt reports seeing hematologist for chronic anemia,
presumed BM suppression [**2-5**] EtOH (hct ~35). Continued iron,
folic acid, MVI.
.
# Thrombocytopenia: This was thought likely to be due to alcohol
or cirrhosis. No e/o active bleeding and similar to prior
measurements.
.
# Cirrhosis: Does not appear acutely decompensated at this time.
Continued nadolol and lactulose.
.
# Hypertension: Blood pressures ranged from 100s to 140s
systolic while he was continued on home dose of lisinopril,
lasix, and nadolol.
.
# Hyperlipidemia: He was continued on home dose of Zetia.
.
# COPD: He was continued on his home regimen of advair and
albuterol/ipratropium nebs as needed.
Medications on Admission:
Albuterol prn
Nadolol 20mg daily (per pt, no longer on atenolol)
Bupropion SR 150mg daily
Ergocalciferol [**Numeric Identifier 1871**] units qmonth
Ezetimibe 10mg daily
Fluticasone-Salmeterol
Folic acid 1mg daily
Furosemide 20mg daily
Levemir 30 units qAM, 35 units qhs
Apidra sliding scale
Lisinopril 10mg daily
Morphine SR 15mg q12h ?
Oxycodone 5-10mg q4h prn pain ?
MVI
Pramlintide (Symlin) 120 mcg 3 times daily before each meal
(dose?)
Topiramate 150mg [**Hospital1 **]
Tramadol 50mg qid prn pain
Iron 325mg daily
Pyridoxine SR 400mg daily
Lactulose 2 tsp tid w/ meals
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q2H (every 2 hours) as needed for
sob/wheezing.
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Levemir 100 unit/mL Solution Sig: Twenty (20) UNITS
Subcutaneous at bedtime.
10. Apidra 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Symlin 600 mcg/mL Solution Subcutaneous
13. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
14. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Pyridoxine 50 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for titrate to 3 BM daily.
17. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypoglycemia, cardiac arrest
secondary: diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for low blood sugar and a cardiac arrest
believed to be because of the low blood sugar. You were feeling
better by the time you got here. We lowered your diabetes
medicines while you were here to prevent low blood sugar in the
future.
When you go home please take your medicines with the following
changes:
1. please DECREASE your apidra sliding scale to the one that we
give you here
2. please DECREASE your levemir to 20 units at night (and none
in the morning)
3. please restart your symlin
Followup Instructions:
Please go to the following appointments:
Name: [**Last Name (LF) 3050**],[**First Name3 (LF) **] S.
Location: [**Hospital6 17557**]
Address: [**Apartment Address(1) 17558**], [**Location (un) **],[**Numeric Identifier 17559**]
Phone: [**Telephone/Fax (1) 15916**]
Appointment: [**2160-4-28**] 11:15am
Department: ADULT SPECIALTIES
When: MONDAY [**2160-6-16**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT SPECIALTIES
When: FRIDAY [**2160-6-20**] at 10:00 AM
With: [**Name6 (MD) 8741**] [**Last Name (NamePattern4) 95699**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: LIVER CENTER
When: THURSDAY [**2160-8-28**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please go to the [**Last Name (un) **] appointment that you already had
scheduled on Tuesday and please also arrange to see your
endocrinologist as soon as possible!!
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2160-4-21**]
ICD9 Codes: 3572, 5849, 5859, 2875, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4556
} | Medical Text: Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-10**]
Date of Birth: [**2046-5-20**] Sex: F
Service:
ADMISSION DIAGNOSES:
1. Rheumatic heart disease.
2. Aortic and mitral valve disease.
DISCHARGE DIAGNOSES:
1. Aortic valve stenosis.
2. Mitral valve regurgitation.
3. Status post aortic valve replacement with 21 mm
pericardial valve, mitral valve repair with 28 mm [**Doctor Last Name 405**]
annuloplasty band.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
woman with a history of rheumatic heart disease. She has
known aortic and mitral valve disease. Her last
echocardiogram was done on [**2109-12-12**] which revealed an ejection
fraction of 60%. Moderately severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 3841**] enlarged
LA were demonstrated as well as moderate to severe aortic
stenosis with an estimated valve area of 0.9 cm squared.
There was also significant pulmonary hypertension with PA
pressures estimated at 64 mmHg. Most recent ETT was negative
in [**2105**] and performed for brief complaints of chest
discomfort. Clinically patient reports that she is very
active. She walks several miles a day, cross country skiis
and is able to cut and stack wood for her fireplace. Over
the past three weeks, however, she has noticed decrease in
activity tolerance along with chest pain and mild shortness
of breath that occurs with vigorous exertion. She reports
that this discomfort can take up to several hours to resolve.
She has never taken nitroglycerin. She is now referred for
cardiac catheterization. Patient denies claudication,
orthopnea, edema, PND, lightheadedness.
PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
Smoking history, quit 20 years ago. Insulin dependent
diabetes mellitus. Rheumatic heart disease. Autoimmune iron
disease. Hypothyroidism. Osteoporosis. Bilateral carotid
bruit without significant carotid disease. Breast cancer
status post chemotherapy and surgery.
PAST SURGICAL HISTORY: Status post left mastectomy in [**2086**].
Cholecystectomy in [**2079**].
MEDICATIONS ON ADMISSION: Miacalcin nasal spray, Levoxyl 200
mcg q.d., Lipitor 10 mg q.d., enalapril 5 mg q.d., Celebrex
200 mg b.i.d., Protonix 40 mg q.d., folate 1 mg q.d., NPH 15
units q.h.s., regular and Humalog insulin sliding scale.
PHYSICAL EXAMINATION: In general, the patient was an elderly
woman who appeared younger than her stated age and was in no
acute distress. Vital signs were stable, afebrile. Height
was 5'2", weight 122 pounds. HEENT was normocephalic,
atraumatic, EOMI, PERRL, anicteric. Throat was clear. Neck
was supple, midline, without masses or lymphadenopathy.
Chest was clear to auscultation bilaterally. Cardiovascular
was regular rate and rhythm with a [**12-26**] to 3/6 systolic
ejection murmur. Abdomen was soft, nondistended, nontender
without masses or organomegaly. Extremities were warm, not
cyanotic, not edematous times four. Neuro was grossly
intact.
LABORATORY DATA: On admission CBC was 12/11.6/35.4/336.
Chemistries 138/4.1/104/27/13/0.7. INR was 1.1.
HOSPITAL COURSE: The patient had cardiac catheterization
performed on [**2109-12-20**] which revealed 3+ mitral valve
regurgitation, calcification of the aortic valve, ejection
fraction of 61%, severe aortic stenosis, normal coronary
arteries. Patient now presents for elective valve repair.
On [**2110-1-6**] patient was taken to the operating room and had
aortic valve placement with a 21 mm pericardial valve and
mitral valve repair with a 28 mm [**Doctor Last Name 405**] annuloplasty band.
Patient was subsequently taken to the CSRU for close
monitoring. Patient did well and was initially A-paced for
blood pressure support. Drips, chest tubes and pacing wires
were discontinued as her clinical condition allowed.
The patient had a largely unremarkable postoperative course
and was subsequently transferred to the floor on
postoperative day two. On the floor her status was again
unremarkable and patient was ambulating well on her own
without physical therapy. Patient did test her own blood
sugar glucoses and maintained her own blood sugars with her
own sliding scale. She is very aggressive about this and
took her finger sticks at least eight times a day.
Ultimately, patient was discharged on postoperative day four,
tolerating a regular diet, had adequate pain control on p.o.
pain meds and had been cleared for home by physical therapy.
The patient was placed on a 10 day course of Levaquin for an
elevated white count of 50 and x-ray finding of some right
lower lobe atelectasis as well as increased clinical sputum
production. Patient remained afebrile.
Physical examination on discharge, in general, in no acute
distress. Vital signs temperature 98.0, heart rate 68, blood
pressure 119/57, respirations 18, 95% in room air. Chest was
clear to auscultation bilaterally. Cardiovascular regular
rate and rhythm. There was no sternal click or sternal wound
drainage. Patient did have 1+ peripheral edema.
Labs on discharge included CBC with white count of 25.4 down
from 26.2, hematocrit 24.1, platelets 235. Chemistries
131/4.9/99/25/30/1.1/65. Magnesium 1.7.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DISCHARGE DIET: Diabetic.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg b.i.d. times seven days.
2. Potassium chloride 20 mEq b.i.d. times seven days.
3. Aspirin 325 mg q.d.
4. Lopressor 12.5 b.i.d.
5. Levaquin 500 mg q.d. times eight days for a 10 day
course.
6. Lipitor 10 mg q.d.
7. Levothyroxine 200 mcg q.d.
8. NPH 15 units q.p.m.
9. Percocet 5/325 one to two q.four hours p.r.n.
10. Colace 100 mg b.i.d.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient is to continue her tight
blood sugar control as well as a diabetic diet. She should
follow up with her cardiologist in one to two weeks to
address the need for continued diuresis as well as adjustment
of cardiac medications at that time. Patient should follow
up with Dr. [**Last Name (Prefixes) **] in four weeks' time. Patient was
instructed to continue Levaquin as well as encourage
incentive spirometry for possible mild respiratory infection.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2110-1-10**] 04:02
T: [**2110-1-10**] 16:08
JOB#: [**Job Number 3842**]
ICD9 Codes: 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4557
} | Medical Text: Admission Date: [**2105-6-18**] Discharge Date: [**2105-6-23**]
Date of Birth: [**2045-12-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
paracentesis
intubation
esophageal balloon placement
History of Present Illness:
59 y/o M who per notes was brought to ED by EMS for altered
mental status. Pt was agitated on exam and unable to give hx.
In the ED he was hypothermic at 91 degrees, with pulse 60, bp
78/50. He had a potassium of 7.4 which was treated with calcium
gluconate, insulin/glucose, and kayexalate. ABG was 7.38/32/70.
Utox demonstrated benzos and opiates. Also noted to have a
bicarb of 12, creatinine of 6.1, BUN 124. In the ED had a
diagnostic paracentesis, which revealed a WBC count of 1200
w/35% polys, 52% lymphs, RBC count 7575. He received
ceftriaxone 2 grams and 4.5 liters of IVF.
Past Medical History:
IDDM
poorly differentiated large cell carcinoma found in ascitic
fluid several months prior to admission, assumed to be HCC
Hep C
EtOH abuse
Social History:
unknown amt of EtOH, tobacco, drugs
Family History:
unknown
Physical Exam:
T: 97 BP 81/48 P: 95 R: 36 95%4LNC
Gen: alert but not answering questions
HEENT: NC, AT. perrl. mm dry.
Lungs: coarse breath sounds with scattered rhonchi
CV: reg rhythm, tachycardic, no m/r/g
Abd: hugely distended. appears TTP. +bs.
Ext: no edema, 1+ dp pulses bilaterally
Pertinent Results:
[**2105-6-18**] 05:34AM BLOOD WBC-12.7* RBC-4.32* Hgb-14.8 Hct-42.6
MCV-99* MCH-34.2* MCHC-34.7 RDW-16.1* Plt Ct-364
[**2105-6-22**] 02:38PM BLOOD PT-15.4* PTT-31.6 INR(PT)-1.6
[**2105-6-18**] 05:34AM BLOOD PT-16.8* PTT-31.3 INR(PT)-1.9
[**2105-6-22**] 02:38PM BLOOD Glucose-143* UreaN-103* Creat-5.2* Na-144
K-4.5 Cl-108 HCO3-15* AnGap-26*
[**2105-6-18**] 05:34AM BLOOD Glucose-228* UreaN-124* Creat-6.1*
Na-129* K-7.6* Cl-94* HCO3-12* AnGap-31*
[**2105-6-22**] 04:00AM BLOOD ALT-64* AST-118* AlkPhos-212*
TotBili-2.2*
[**2105-6-18**] 02:23PM BLOOD Acetone-NEGATIVE
[**2105-6-18**] 05:57AM BLOOD Ammonia-78*
[**2105-6-18**] 01:54PM BLOOD Cortsol-43.4*
[**2105-6-18**] 12:40PM BLOOD Cortsol-45.0*
[**2105-6-18**] 07:00AM BLOOD PEP-NO SPECIFI
[**2105-6-18**] 05:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2105-6-22**] 04:35AM BLOOD Type-ART Temp-36.1 Rates-20/ Tidal V-550
PEEP-10 FiO2-40 pO2-88 pCO2-35 pH-7.32* calHCO3-19* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2105-6-21**] 07:57PM BLOOD Lactate-4.0*
[**2105-6-19**] 12:19PM BLOOD Lactate-6.8* K-5.2
CTA AORTA: The aorta demonstrates a normal contour and caliber
throughout its visualized course without any filling defects. No
filling defects or pulmonary emboli are identified within the
pulmonary arterial system.
CT OF THE CHEST W/IV CONTRAST: Soft tissue window image
demonstrate multiple lymph nodes within the mediastinum, within
the pretracheal, subcarinal, and perivascular spaces. Several of
these are enlarged by CT criteria, measuring up to 13 mm in
short axis diameter. The great vessels, heart, pericardium are
normal. No axillary lymphadenopathy is seen. No pleural
effusions. Lung window images demonstrate innumerable nodules
within both lungs diffusely, likely representing metastatic
foci. No parenchymal consolidation is seen. The airways are
patent to the level of the segmental bronchi bilaterally.
CT OF THE ABDOMEN W/IV CONTRAST: There is massive ascites.
Within the liver, there are several focal masses in the right
lobe of the liver, the largest of these measures 9 x 5.9 cm. In
the left lobe of the liver, a smaller nodule, measuring 2.3 x
2.2 cm is seen. Additionally, in the inferior tip of the right
lobe of the liver, there is a lesion measuring 6 x 2.5 cm. These
findings may represent a primary hepatic malignancy.
Additionally, there is caking of the omentum, representing
omental metastatic disease. The spleen, kidneys, and pancreas
are normal. The bowel appears normal, without any evidence of
bowel wall dilatation. The small bowel is floating within the
ascites. There is increased density within the gallbladder, and
within the large colon. These findings suggest the patient has
had recent ERCP, and this density represents contrast.
Correlation to clinical history is recommended. No free
intraperitoneal air is seen.
CT OF THE PELVIS W/IV CONTRAST: A large amount of pelvic fluid
can be seen. The bladder contains a Foley catheter. The rectum
appears normal.
BONE WINDOWS: No suspicious lytic or sclerotic lesion
identified.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in delineating the anatomy and pathology.
IMPRESSION:
1) No aortic dissection.
2) Several masses are seen within the liver, in both lobes.
These may represent a primary hepatic malignancy. There is
diffuse metastatic disease within the lungs, with innumerable
pulmonary nodules. Additionally, there are omental metastases.
Further evaluation of the liver with a multiphasic liver CT is
recommended.
3) Massive ascites.
4) The gallbladder contains dense material, which most likely
represents contrast from recent ERCP. Correlation to clinical
history is recommended.
CT HEAD WITHOUT IV CONTRAST: No intraparenchymal, subarachnoid,
or subdural hemorrhage is seen. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. No intracranial mass effect is
identified. The ventricles are prominent, symmetric, and there
is no shift of normally midline structures. There is a small
area of decreased attenuation in the right anterior
putamen/internal capsule which is probably a chronic infarction.
The density of the cortex is within normal limits. Soft tissue
and osseous structures are normal.
IMPRESSION: No intracranial hemorrhage or mass effect.
Peritoneal fluid cytology: Peritoneal fluid, cell block:
Highly atypical scattered cells mostly seen in cytology
preparation (see cytology report C05-[**Numeric Identifier 39373**]). Immunohistochemical
studies for AE1/AE3, CAM 5.2, CEA, Leum1, Calrentinin, B72.3,
Hepar-1, CD10 are non contributory.
Brief Hospital Course:
He was admitted to the MICU on the sepsis protocol. It was felt
that he had SBP and likely had malignant ascites. His primary
malignancy was likely hepatocellular, as CT chest/abd/pelvis
demonstrated large lesions in the liver as well as innumerable
pulmonary nodules. He was intubated on the night of admission
[**3-11**] inability to continue compensating for his acidosis. He was
increasingly hypotensive and was placed on levophed. He was
anuric. It was felt that one of the reasons he couldn't be
ventilated was that his distended abdomen was restricting his
diaphragm, so an esophageal balloon was placed to monitor
transpulmonary pressures. He also underwent repeat paracentesis
to attempt to decrease ascites and help his respiratory status.
5 liters of ascites were removed. 2 days later he had another
paracentesis, with another 5 liters removed. The renal service
was following him but he did not require dialysis. His wife and
daughter arrived from [**Name (NI) 19061**], and felt that he would have
wanted everything done. However, after repeat meetings, and
because of the fact that the pt did not pursue Oncology f/u when
his cancer was diagnosed per PCP, [**Name10 (NameIs) **] was decided to make him
DNR. His family did not want to withdraw care, but they did not
want to escalate care. He became increasingly hypotensive and
then became asystolic. He died on [**2105-6-23**] with his family by
his side.
Medications on Admission:
vicodin prn
humulin
lasix
indural
protonix
multivitamin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic hepatocellular carcinoma
sepsis
respiratory failure
renal failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 0389, 5715, 2765, 5845, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4558
} | Medical Text: Admission Date: [**2183-12-24**] Discharge Date: [**2184-1-6**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Generally asymptomatic, slight dyspnea with walking greater than
150 feet
Major Surgical or Invasive Procedure:
[**2183-12-24**]
1) Coronary artery bypass grafting x3, left internal
mammary artery graft to left anterior descending,
reverse saphenous vein graft to the marginal branch and
ramus intermedius.
2) Aortic valve replacement, 23-mm Biocor Epic tissue
valve.
3) Aortic endarterectomy.
History of Present Illness:
85yo man with known aortic stenosis followed by serial
echocardiograms over last 3 years. Presents for surgical
evaluation.
Cardiac Catheterization:
[**2183-12-3**] [**Hospital3 20284**] Center, [**Hospital1 189**]
1. Critical AS [**Location (un) 109**] 0.7cm2
2. normal to hyperdynamic LV systolic function
3. mild pulmonary htn
4. systemic htn
5. cors:
LM 50% distal
RI 90%
LAD 30% mid
RCA near normal
6. calcified aortic arch
[**2183-10-17**] Echocardiogram: LVEF 65%. Severe aortic stenosis
with [**Location (un) 109**] 0.7cm2 with mean gradient of 76mmHg, mild aortic
insufficiency. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Mild pulmonary HTN(PASP
42mmHg). Normal aortic dimensions-root 3.0.
Carotid Ultrasound: 40-59% bilaterally
Past Medical History:
Aortic Stenosis/aortic insufficiency s/p AVR/CABG [**2183-12-24**]
Coronary artery disease
Hypertension
Paroxysmal atrial fibrillation
Benign Prostatic Hypertrophy
Chronic Renal Insufficiency(creatinine 1.6) with acute kidney
injury this admission due to hypovolemia (Cr rose to 3.0)
Past Surgical History: Inguinal hernia repair
Social History:
Race: Caucasian
Last Dental Exam: [**2183-5-17**], will schedule exam before surgery
Lives with: Son and daughter-in-law
Occupation: Retired printer
Tobacco: Quit 40 years ago
ETOH: [**2-19**] glasses of wine/year
Family History:
Non contributory
Physical Exam:
Pulse:79 Resp: 18 O2 sat: 100%-RA
B/P Right:138/53 Left: 131/50
Height: 5'8" Weight: 184lbs
General: NADS
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x] MMM-normal oropharynx
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: A&O x3, MAE, non focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: - Left: -
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit -radiated murmur bilaterally
Discharge Physical Exam:
VS:
General: 85 year-old male no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck; supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
GI: benign
Extr: warm 3+ edema
Incision: sternal clean, dry intact, bilateral extremities clean
dry intact
incision upper thigh area with scab
Neuro: awake, alert, oriented. moves all extremities
Pertinent Results:
[**2184-1-3**] Hct-27.7
[**2184-1-2**] WBC-6.6 RBC-3.29* Hgb-9.9* Hct-29.8* MCV-91 MCH-30.0
MCHC-33.1 RDW-14.4 Plt Ct-178
[**2183-12-30**] WBC-6.9 RBC-3.26* Hgb-10.0* Hct-30.2* MCV-93 MCH-30.6
MCHC-33.0 RDW-14.6 Plt Ct-138*
[**2184-1-4**] Glucose-95 UreaN-66* Creat-2.0* Na-139 K-4.1 Cl-107
HCO3-26
[**2184-1-3**] UreaN-79* Creat-2.2* Na-141 K-4.2 Cl-109*
[**2184-1-2**] Glucose-93 UreaN-82* Creat-2.3* Na-141 K-4.2 Cl-109*
HCO3-25
[**2183-12-30**] Glucose-103* UreaN-80* Creat-2.6* Na-145 K-3.7 Cl-109*
HCO3-25
[**2183-12-29**] Glucose-95 UreaN-71* Creat-2.8* Na-142 K-3.8 Cl-109*
HCO3-24
[**2183-12-29**] Glucose-85 UreaN-60* Creat-2.3* Na-144 K-3.2* Cl-116*
HCO3-22
[**2183-12-28**] Glucose-112* UreaN-70* Creat-2.9* Na-141 K-3.7 Cl-109*
HCO3-25
[**2183-12-28**] Glucose-101* UreaN-64* Creat-3.0* Na-139 K-3.6 Cl-107
HCO3-24
[**2183-12-24**] Echo
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. 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. There are simple atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is mild valvular mitral stenosis (area 1.5-2.0cm2). Mild to
moderate ([**1-18**]+) mitral regurgitation is seen.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve noted in the aortic position. The valve appears well
seated. The leaflets are difficult to visualize. Mild mitral
regurgitation present. Aorta is intact post decannulation
CXR
[**2183-12-31**]: IMPRESSION: Persistent patchy left lower lobe opacity,
but probably somewhat improved, with a suspected tiny residual
pleural effusion.
[**2183-12-24**]: FINDINGS: In comparison with a preoperative study,
there has been a CABG procedure performed. Endotracheal tube tip
lies approximately 7 cm above the carina and is at the mid
clavicular level. Right IJ Swan-Ganz catheter is in the right
pulmonary artery. Nasogastric tube is coiled in the fundus of
the stomach. Left chest tube is in place and there is no
pneumothorax. Retrocardiac atelectasis is seen.
IMPRESSION: Standard appearance following CABG.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2183-12-24**] where the patient underwent coronary
artery bypass grafting x3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the marginal branch and ramus
intermedius and aortic valve replacement with 23-mm Biocor Epic
tissue valve. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. He did have some post
operative confusion requiring Haldol. At the time of discharge
he was oriented x 3 and not requiring Haldol. 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. He did have post
operative ATN with a peak crea to 3.0 and peak BUN to 85. Lasix
was decreased and his renal function was stable at the time of
discharge with BUN 66, CRE 2.0. He was hypertensive amlodipine
was started the ACE held secondary to his renal function. While
working with PT his systolic blood pressure was 190. He was
started on hydralazine with good effect. His Foley catheter had
to be reinserted on POD4 for urinary retention. He was
restarted on his home dose of Terazosin and Foley was removed
again on POD6 and he did void successfully. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 12 the
patient was ambulating independently the wound was healing and
pain was controlled with Tylenol. The patient was discharged to
home with VNA and PT. He will have his renal function checked
on [**2184-1-6**]. He will follow-up with his nephrologist Dr.
[**Last Name (STitle) 88186**] in 2 weeks and Dr. [**Last Name (STitle) **] and his PCP in one month.
Medications on Admission:
Amiodarone 200 QD
Hydrochlorthiazide 25 QS
Lisinopril 40 QD
Lovastatin 20 QD
Terazosin 2 WQD
MVI
Allergies:NKDA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-18**] puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*qs inhaler* Refills:*1*
9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Chem 7 BUN & CRE.
Please call [**Doctor First Name **] at Dr.[**Name (NI) 5572**] office [**Telephone/Fax (1) 170**] with
results.
11. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
Palm [**Hospital 731**] Nursing Home - [**Location (un) 15749**]
Discharge Diagnosis:
Aortic Stenosis/aortic insufficiency s/p AVR/CABG [**2183-12-24**]
Coronary artery disease
Hypertension
Paroxysmal atrial fibrillation
Benign Prostatic Hypertrophy
Chronic Renal Insufficiency(creatinine 1.6) with acute kidney
injury this admission due to hypovolemia (Cr rose to 3.0)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. [**2-19**]+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**2183-1-29**] at 2:15 PM
Cardiologist: Dr [**Last Name (STitle) 5655**] on [**2183-2-13**] at 9:00 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1169**] [**Last Name (NamePattern1) 79**] in [**4-21**] weeks
Please call Dr.[**Name (NI) 88187**] office (nephrologist) [**Telephone/Fax (1) 24335**] for
an appointment within 2 weeks
Blood draw on Tuesday with VNA Electrolytes BUN/CRE. Please
call results to [**Doctor First Name **] at Dr.[**Name (NI) 5572**] office [**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**
Completed by:[**2184-1-5**]
ICD9 Codes: 4241, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4559
} | Medical Text: Admission Date: [**2143-4-16**] Discharge Date: [**2143-4-23**]
Date of Birth: [**2071-5-31**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Gadolinium-Containing Agents
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Severe disabling claudication with malfunctioning of left
axillary bifemoral graft with bilateral femoral artery stenoses
and partial thrombosis of femoral-femoral crossover graft.
Major Surgical or Invasive Procedure:
[**4-17**] OR: L ax-fem revision with 6mm PTFE, fem-fem with 6mm PTFE
History of Present Illness:
71 year old f s/p RT CIA-bifem bypass with Dacron in [**2137**]
complicated by thrombus. Then has LT axillary to fem/fem bypass
in [**2137**]. Restenosis noted during follow up duplex/MRA.
Diagnostic angiogram on [**2143-3-27**] revealed patent distal
axillofemoral bypass with moderate stenosis in the midportion of
graft and high grade stenosis at the proximal anastamosis.
Required surgical revision. Patient admitted for planned surgery
in am.
Past Medical History:
PMH: rheumatoid arthritis, cad, mi, osteoarthritis, lung ca with
rul resection s/p chem and xrt. gerd, HTN,
PSH: ballon angioplasty x 2 rle [**2129**], rul resection with xrt /
chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel
release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands, RCIA to
bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by
thrombus then had Left axillary to fem - fem BPG [**2137**], benign
growth removal colon
Social History:
lives at home, uses wheel chair
Family History:
n/c
Physical Exam:
VS: 97.3, 101/38, 16 RA 96%RA
Neuro A+OX3
Lungs: CTA
CARDS: RRR
ABD: soft, NT
Pulses: B/L DP/PT doppler
Pertinent Results:
[**2143-4-22**] 05:08AM BLOOD WBC-6.4 RBC-3.01* Hgb-9.6* Hct-27.0*
MCV-90 MCH-31.8 MCHC-35.5* RDW-14.6 Plt Ct-230
[**2143-4-22**] 05:08AM BLOOD Plt Ct-230
[**2143-4-22**] 05:08AM BLOOD PT-13.0 INR(PT)-1.1
[**2143-4-22**] 05:08AM BLOOD Glucose-97 UreaN-14 Creat-1.5* Na-137
K-3.7 Cl-99 HCO3-34* AnGap-8
[**2143-4-22**] 05:08AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
Brief Hospital Course:
Admitted preop for fem-fem revision. Preop labs, ECG obtained.
patient has had all PAT as outpatient. Home medications resumed.
[**2143-4-17**]: No overnight events. Underwent Revision of left
axillary-femoral graft with jump graft, a 6 mm PTFE and left to
right femoral-femoral bypass
with 6 mm PTFE graft. Extubated and transfered to PACU. VSS.
Pain controlled. Transfered to VICU when bed was available.
[**2143-4-18**] VSS. Transfused 1uPRBCs for HCT 25. Diet advanced. B/L
DP/PT pulses dopplerable. IVF heplocked. Patient kept on bedrest
today.
[**2143-4-19**] Stroke team called to evaluate patient secondary to
confusion. Her
exam is notable for inattention and bilateral asterixis, in
addition to signs of peripheral neuropathy that is chronic. She
is not a candidate for tPA for several reasons; chiefly, her
event is not consistent by history with stroke, she has no acute
neurologic deficits and her recent surgery. All signs point to
encephalopathy, likely infectious or toxic/metabolic in origin.
Impression: encephalopathy. Pain medications held. Chest x-ray
showing stable examination with no acute pulmonary process.
[**2143-4-20**] Temp of 101.8- cultures sent. Urine Cx negative, blood cx
negative to date (at discharge). WBC WNL. all lines discontinued
[**2143-4-21**]: Temp of 101.8- encourage OOB, incentive spirometry.
Transfused with 1uPRBCs. IV lasix given.
[**2143-4-22**]: No overnight events. T 99.3- 97.3. Patient OOB with
nursing staff. Physical therapy consult obtained for home safery
vs rehab evaluation . Continued on ASA, Coumadin and SQ heparin.
Medications on Admission:
Doxepin 25 ", dIGITEK 0.25, TENORMIN 12.5 ", LIPITOR 40, FOLGARD
RX, ASA 81, PRILOSEC 20 ", DULCOLAX 20 ", MECLIZINE 12.5 NOON,
LORAZEPAM 0.5 QHS, COUMADIN 3, ALDACTAZIDE 25 MG m/w/f, FYNTNAL
PATCH Q 72 HOURS, LIDODERM PATCH Q 12 ON / OFF, VIT B-6 50,0000
IU,
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
10. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical 12 HRS ON /12 HRS OFF
(): 1 PTCH TD 12 HRS ON /12 HRS OFF.
12. 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*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): Continue anticaogulation by primary care MD
[**Last Name (LF) **],[**First Name3 (LF) 198**] B. [**Telephone/Fax (1) 8363**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
71F s/p RCIA to bifemoral BPG with 6mm dacron PTFE [**2137**] /
complicated by thrombus then had Left axillary to fem - fem BPG
[**2137**].
[**4-17**] OR: L ax-fem revision with 6mm PTFE, fem-fem with 6mm PTFE
.
PMH: rheumatoid arthritis, cad, mi, osteoarthritis, lung ca with
rul resection s/p chem and xrt. gerd, HTN,
PSH: ballon angioplasty x 2 rle [**2129**], rul resection with xrt /
chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel
release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands, RCIA to
bifemoral BPG with 6mm dacron PTFE [**2137**] / complicated by
thrombus then had Left axillary to fem - fem BPG [**2137**], benign
growth removal colon
Discharge Condition:
Good.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-19**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr.[**Name (NI) 5695**] office to schedule a post op visit to be
seen in [**9-29**] days. [**Telephone/Fax (1) 3121**]
Completed by:[**2143-4-23**]
ICD9 Codes: 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4560
} | Medical Text: Admission Date: [**2187-7-17**] Discharge Date: [**2187-7-26**]
Date of Birth: [**2112-12-8**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac ablation
Cardiac catheterization with stenting of RCA
History of Present Illness:
73 year old woman with ho paroxysmal afib, DM, HTN, and
dyslipidemia presents with SOB. She was well until 6 pm [**7-17**]
when she developed sudden SOB at rest. Onset over 4-5 minutes.
No chest pain or pressure. No jaw or arm sx. No diaphoresis,
fever, or chills, although she notes nonproductive cough x 1
week. Mild bilateral lower extremity edema over the past month,
with increase over prior week. No orthopnea, PND, or nocturia.
No change in diet or medications. No ho SOB. No recent surgery
or immobilization, and she is on coumadin for afib. She called
EMT and felt better upon administration of oxygen, nitrates, and
lasix in the field. She has felt back to normal since then.
.
ROS: nonbloody diarrhea x 2 days
Past Medical History:
1. HTN
2. Hyperlipidemia
3. DM
4. Rheumatic fever
5. Paroxysmal atrial fib s/p unsuccessful cardioversion [**2187-6-29**]
6. ?CHF: Stress TTE in [**2181**] showed EF=40-45%, mild global LV
hypokinesis, severely hypokinetic septum, mild MR/AR/TR
7. Diverticulitis, s/p partial colectomy in [**2180**] (temporary
colostomy with reversal)
8. Ulcerative colitis, inactive per c-scope earlier this year
9. Left Carotid artery stenosis (50-80% [**2185**])
10. Left Hip fracture, s/p repair [**2184**]
Social History:
Widowed, lives with son, has three children
Quit smoking 25 yrs ago, denies etoh or drug use
Worked as Unit secretary at [**Hospital1 882**] ICU
Family History:
2 sisters with afib, father with MI, mom with aneurysm
Physical Exam:
PE: 99 96 109-119 120-140/80's 20 96% (3L nc) 62.8 kg
NAD
PEERL, JVP 15, L carotid bruit
RRR no m/r/g
bibasilar crackles, reduced BS at bases, dull to percussion [**1-2**]
up chest bilaterally
Abd soft, mod distended, nl BS, no HSM
Ext: warm, 2+ dorsal and tibial pulses, sensation intact, no
ulceration
Pertinent Results:
[**2187-7-17**] 08:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2187-7-17**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2187-7-17**] 08:15PM GLUCOSE-280* UREA N-18 CREAT-1.0 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2187-7-17**] 08:15PM CK(CPK)-125
[**2187-7-17**] 08:15PM CK-MB-3 cTropnT-<0.01
[**2187-7-17**] 08:15PM CALCIUM-9.0 PHOSPHATE-4.3
[**2187-7-17**] 08:15PM WBC-18.3*# RBC-4.15* HGB-10.5* HCT-34.6*
MCV-83 MCH-25.3*# MCHC-30.4* RDW-14.8
[**2187-7-17**] 08:15PM NEUTS-74.5* LYMPHS-18.6 MONOS-3.1 EOS-3.7
BASOS-0.2
[**2187-7-17**] 08:15PM HYPOCHROM-1+ MICROCYT-1+
[**2187-7-17**] 08:15PM PLT COUNT-431
[**2187-7-17**] 08:15PM PT-23.0* PTT-26.5 INR(PT)-3.5
Brief Hospital Course:
73 yo woman with multiple cardiac risk factors admitted to
medicine for further work up of acute-onset SOB.
1. Shortness of breath: ECG notable for Q waves in V1 V2 and V3,
but Ms. [**Known lastname **] [**Last Name (Titles) 20003**] out for acute MI with negative cardiac
enzymes. Low suspicion for PE given absence of risk factors. No
consolidation on CXR, so pneumonia unlikely in this afebrile
patient. Cardiac echo and pMIBI notable for EF 25% and fixed
anterior wall defect. In combination with clinical signs of
volume overload, including dependent edema and elevated JVP,
this suggested SOB secondary to CHF exacerbation. In addition,
MS. [**Known lastname **] [**Last Name (Titles) 65974**] to afib, often with aberrant conduction,
early on in her hospital course, noting increased "fatigue" at
those times. However, exact trigger for CHF exacerbation prior
to admission is unclear.
.
2. Cardiac: Ms. [**Known lastname **] was found to have EF 27% and fixed
anterior wall defect in the LAD territory. In addition, she
developed a sustained tachyarrhythmia, determined to be atrial
fib/flutter with aberrancy, on [**7-20**]. Arrhythmia was associated
with "fatigue" but no other symptoms. EP was consulted and felt
that she would benefit from attempted cardioversion and ablation
of atrial focus, as medical rate control was ineffective at that
time. Both were attempted [**7-20**], however she [**Month/Year (2) 65974**] to afib
within 24 hours. We then utilized pharmocologic rate control
until [**7-23**], when she underwent cardiac catheterization. Cath
showed 90% RCA stenosis, which was stented, and 50% LAD stenosis
with good flow. During the procedure she was noted to have a
poor cardiac index, consistent with baseline, and started on
dobutamine drip for extra support. She was transfered to the CCU
in good condition, and then returned to medicine on [**7-24**] for
optimization of volume status prior to discharge. She remained
stable throughout, and was discharged to home in good condition,
weight 60 kg, and NSR.
.
3. Pulmonary: Pulmonary edema with small bilateral effusions,
consistent with CHF flare, were managed with gentle diuresis. In
addition, CXR was notable for a nodule on the right, which may
be artifact, secondary to amniodarone tox, or other. Should
follow up with PCP.
.
4. Anemia: Upon admission, she was noted to be slightly anemic,
with Hct 35. Over the ensuing week, during which time she
underwent [**Hospital1 **] phlebotomy and two cardiac procedures, it reached
a nadir of 27, for which she was transfused pRBC x 2. FOBT
negative throughout, abd benign, no hematoma, and no back pain
suggestive of retroperitoneal bleed. Iron studies were normal,
and Hct stable x 3 days at time of discharge.
.
5. Colitis: Frequent brown, nonbloodly, watery stools during
this admission. Afebrile, without abdominal pain, nausea or
vomiting. FOBT negative x 3. Felt to represent ulcerative
colitis flare. Will continue asacol QID and imodium PRN
.
6. Endocrine: Maintained on regular insulin sliding scale with
good glycemic control. Restarted glyburide prior to discharge.
.
7. Health maintenance: Pt did not receive Pneumovax during this
hospitalization. Pt/PCP should discuss the need for Pneumovax
administration.
Medications on Admission:
Asacol 800 mg QID
Glyburide 5 mg QD
Toprol XL 150 mg daily
Lasix 40 mg qd
Cartia XT 360 mg qam
Coumadin 5 mg qTThSaSu/2.5 mg MWF
Amiodarone 400 mg daily
Lipitor 20 QD
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QID (4 times a day).
2. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for colitis flare.
Disp:*30 Capsule(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
Disp:*4 syringe* Refills:*0*
14. Outpatient Lab Work
INR check weekly
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Congestive heart failure
Atrial fibrillation with aberrancy
Coronary artery disease
Anemia
Ulcerative colitis flare
Discharge Condition:
Good
Discharge Instructions:
1. Please weigh yourself with an electronic scale first thing
days.
.
2. Please follow a diet that is low in added salt.
.
3. Please call your doctor if you have chest pain, shortness of
breath, back pain, nausea, vomiting, dizziness, or other
symptoms concerning to you.
.
4. Please have your INR checked next Monday ([**2187-7-30**]) and modify
your lovenox and coumadin regimens as directed by your doctor.
Followup Instructions:
1. Please have your INR level checked on Monday [**2187-7-30**], and
adjust your coumadin and lovenox as directed by your doctor.
.
2. Please see your primary care doctor in [**12-31**] weeks to follow up
on your heart failure, anemia, and changes see on chest x-ray.
.
3. Please see your cardiologists as follows:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2187-7-27**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2187-10-8**] 4:00
Completed by:[**2187-7-26**]
ICD9 Codes: 2724, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4561
} | Medical Text: Admission Date: [**2153-5-3**] Discharge Date: [**2153-5-12**]
Date of Birth: [**2116-6-9**] Sex: F
Service: SURGERY
Allergies:
Erythromycin / Latex / Bactrim / Penicillins / Adhesive Bandage
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
sigmoidoscopy [**2153-5-10**]
History of Present Illness:
36f s/p pancreas transplant [**2-13**] notes 3 weeks of loose,
watery stools, food and medication intolerance, and, more
recently, BRBPR. She presented today to Dr[**Name (NI) 8584**] clinic, at
which time she was noted to be pale, hypotensive to the 80's,
tachycardic, and feeling very week. She was directly sent to
the
ER for further evaluation. Here she notes no abdominal pain,
recent melena, no further continued vomiting, no fevers, chills
or other constitutional symptoms. She appears with substantial
pallor, poor skin turgor, dry eyes and mucous membranes, and
states that she feels exhausted. Additionally, she is
neutropenic, acidotic with a HCO3 of 9, and anemic -- these
laboratory values are all substantial deviations from her prior
baseline. Also, her blood sugars have been noted by the patient
as being in the 170s, fasting, but she is found to have a
quick-fingerstick of 142 and a chemistry-glucose of 157.
Past Medical History:
DM1, hyperlipidemia, exploratory laparotomy for
endometriosis, C-section, left frozen shoulder s/p multiple
surgeries, and migraines.
Social History:
Denies ETOH, smoking, recreational drugs. Currently on
disability [**1-23**] her left shoulder pain.
Family History:
Significant for diabetes. Father had melanoma.
Physical Exam:
Physical exam on discharge:
AF, VSS
General: NAD, alert and oriented x 3
CV: RRR, no m/g/r
Pulm: CTAB, no rales/rhonchi/wheezes
Abd: soft, non-distended, mild tenderness to palpation in RLQ.
Well-healed vertical midline incision.
Ext: wwp, no edema
Pertinent Results:
Admission labs:
[**2153-5-3**] 11:25AM BLOOD WBC-0.6*# RBC-4.25 Hgb-12.3 Hct-36.8
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.6 Plt Ct-358
[**2153-5-3**] 01:10PM BLOOD Neuts-91* Bands-1 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2153-5-3**] 01:10PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
[**2153-5-3**] 11:25AM BLOOD Plt Ct-358
[**2153-5-3**] 01:10PM BLOOD PT-14.0* PTT-29.4 INR(PT)-1.2*
[**2153-5-3**] 01:10PM BLOOD Plt Smr-NORMAL Plt Ct-277
[**2153-5-3**] 11:25AM BLOOD UreaN-87* Creat-5.7*# Na-131* K-4.1 Cl-98
HCO3-14* AnGap-23*
[**2153-5-3**] 11:25AM BLOOD Glucose-190*
[**2153-5-3**] 11:25AM BLOOD ALT-12 AST-24 Amylase-123* TotBili-0.3
[**2153-5-3**] 11:25AM BLOOD Lipase-62*
[**2153-5-3**] 11:25AM BLOOD Albumin-4.6 Calcium-9.8 Phos-7.0*#
[**2153-5-3**] 11:25AM BLOOD %HbA1c-4.8 eAG-91
[**2153-5-3**] 11:25AM BLOOD tacroFK-GREATER TH
[**2153-5-3**] 04:55PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-32* pH-7.24*
calTCO2-14* Base XS--12 Comment-GREEN TOP
[**2153-5-3**] 01:17PM BLOOD Lactate-1.3 K-3.7
[**2153-5-3**] 01:17PM BLOOD Hgb-10.8* calcHCT-32
Discharge labs:
[**2153-5-11**] 06:10AM BLOOD WBC-4.6 RBC-3.32* Hgb-9.5* Hct-28.0*
MCV-84 MCH-28.5 MCHC-33.8 RDW-15.8* Plt Ct-168
[**2153-5-11**] 06:10AM BLOOD Plt Ct-168
[**2153-5-11**] 06:10AM BLOOD Glucose-103* UreaN-2* Creat-0.8 Na-140
K-4.5 Cl-114* HCO3-23 AnGap-8
[**2153-5-11**] 06:10AM BLOOD Amylase-55
[**2153-5-11**] 06:10AM BLOOD Lipase-14
[**2153-5-11**] 06:10AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.5*
[**2153-5-11**] 06:10AM BLOOD tacroFK-8.7
Micro:
[**2153-5-3**]:
BLOOD/FUNGAL CULTURE (Final [**2153-5-7**]):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR FUNGUS.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ISOLATED FROM ONE SET ONLY.
BLOOD/AFB CULTURE (Final [**2153-5-6**]):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR AFB.
Myco-F Bottle Gram Stain (Final [**2153-5-5**]):
GRAM POSITIVE ROD(S) CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 9604**] [**Last Name (NamePattern1) 41183**] AT 2103 ON [**2153-5-5**].
[**2153-5-3**] 5:30 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2153-5-5**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2153-5-10**] 11:47 am
BIOPSY Site: COLON
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Virus isolated so far.
Fecal culture negative x 2, ova and parasites negative x 3.
Blood cultures negative x 2, urine culture negative x 1.
All other cultures negative or pending. Please refer to the
online medical record for details.
Brief Hospital Course:
36 y/o female aditted through the ED with loose stools and most
recently BRBPR. She was admitted directly from the ED to the
SICU.
A CT was obtained but without contrast there was no large fluid
collection or hematoma visualized. The assessment of the
pancreatic transplant is limited; however, there are no gross
fluid collections or inflammatory changes present.
Also seen is abdominal rectus diastasis with paraumbilical
hernia containing a single loop of herniated bowel, with no
evidence of bowel obstruction.
She received large volume resuscitation, and 2 units of RBC's on
[**5-3**] for hct 21% and then 2 units RBCs on [**5-4**] for 26%.
Following these transfusions her hematocrit remained stable and
the rectal bleeding had ceased.
On [**5-4**] a tagged Red cell scan was performed, and this did not
show evidence of active bleeding.
Blood cultures collected on admission and then during the
hospitalization were all negative.
CMV viral load and CMV antibody are both negative.
Stool culture, O&P and C diff x 3 were collected and were all
negative.
The patient continued to have multiple loose stools.
She was consulted to the GI service who performed a colonoscopy.
The results were: Normal mucosa in the colon and terminal ileum
with cold forceps biopsies taken wich were not finalized at
discharge. She also had Grade 3 internal hemorrhoids
Otherwise normal colonoscopy to terminal ileum.
She was started on immodium which helped decrease number of
stools.
Immunosuppression was changed during this hopsitalization. She
was discontinued off Cellcept, and after a few days of
monotherapy on Prograf, she was started on imuran, for which she
received a script for home.
She was taken off valcyte after it was determined her CMV status
was negative, and she is out approximately 3 months from
transplant.
ID consult had been obtained early in hospital course. They
followed with antibiotic recommendations, and suggestions
regarding neutropenia. She was initially covered with Levaquin,
Vanco and Flagyl, this was eventually trimmed to Flagyl only and
then no antibiotics for home were recommended.
She was also profoundly neutropenic, and part of adjusting
medications was goal of increasing WBCs as well as 7 days of
Filgrastim. WBC nadir was 0.2.
Upon discharge her stools had been mnimized, immunosuppression
was adjusted and she was tolerating diet.
She has also been followed by social work who will also be
following her as an outpatient due to concerns that she needs
encouragement to call earlier when not feeling well.
Medications on Admission:
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 180
mg
Tablet - 1 Tablet(s) by mouth once a day
METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth three times a day
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 1 Tablet(s) by mouth
four
times a day
PENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 300 mg ih monthly
dilute in 6 ml of sterile water
SODIUM POLYSTYRENE SULFONATE - Powder - Take 15 gms as
directed
prn for high k dispense 464 gms
TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3
Capsule(s) by mouth twice a day take up to 4 capsules [**Hospital1 **]
TACROLIMUS - (Dose adjustment - no new Rx) - 0.5 mg Capsule - 1
Capsule(s) by mouth twice a day
VALGANCICLOVIR [VALCYTE] - 450 mg Tablet - 2 Tablet(s) by mouth
once a day
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times
a day.
4. Pentamidine 300 mg Recon Soln Sig: One (1) inhalation
Inhalation once a month.
5. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO every twelve
(12) hours: Please have your tacrolimus levels drawn weekly and
follow up for dose changes.
6. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Myfortic Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
Diarrhea
fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please have your tacrolimus levels drawn weekly and follow up
for dosage changes.
Please call the Transplant office [**Telephone/Fax (1) 41184**] if you
experience any of the warning signs listed below:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications except for cellcept
and valcyte. Also, please take any new medications as
prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink enough fluid to keep your urine pale yellow
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 673**] [**2153-5-18**]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-6-8**] 9:50
Completed by:[**2153-5-14**]
ICD9 Codes: 5849, 5789, 2762, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4562
} | Medical Text: Admission Date: [**2185-8-1**] Discharge Date: [**2185-8-2**]
Date of Birth: [**2102-8-31**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
pericardial effusion/tamponade
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 82 y/o female with PMHx CAD who presents from
[**Hospital **] hospital with concern of pericardial effusion/tamponade.
The patient had a pacemaker placed 1 month ago by Dr.
[**Last Name (STitle) 23246**]. She had been feeling well until approximately 1 week
ago when she suddenly had the onset of decreased energy,
fatigue, decreased taste, a burning sensation in her stomach,
and loose stools. She had a routine check-up with her
cardiologist today who sent her to the ED after hearing her
symptoms. In the [**Location (un) **] ED, her vital signs were 98.8 73
122/53 22 94% RA. She had an echo performed which showed a
pericardial effusion and concern for tamponade. She was
transferred to [**Hospital1 18**] for further management.
On review of systems, she does admit to ~1 month of [**3-2**]
sharp, substernal chest pain with no radiation as well as
dyspnea that she would get when she walked up stairs. It would
dissipate with rest. She also admits to having trouble
breathing when she lies flat and has been sleeping in an
inclined chair the past 2 weeks. There has also been increased
ankle swelling. She did have chest pain last night, for which
she took 2 sublingual nitros.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.
Past Medical History:
-Hypertension
-PACING/ICD: Pacer placed 1 month ago with Dr. [**Last Name (STitle) 23246**]
[**Name (STitle) 87455**]
Social History:
-Tobacco history: 1ppd x20 yrs, quit 20 yrs ago
-ETOH: 1 glass wine daily
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother with renal cell cancer.
Physical Exam:
GENERAL: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. mild conjunctival
pallor.
NECK: Supple with JVP to jawline, no carotid bruits, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregular rate, rhythm, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Decreased breath sounds left lung base,with b/l crackles
ABDOMEN: Soft, non-distended. +bowel sounds, scar anterior
abdomen. mild tenderness to deep palpation, suprapubic. No
guarding/rebound.
EXTREMITIES: 2+ pitting edema bilaterally to mid calf, 2+ DP/PT
pulses.
Pertinent Results:
[**2185-8-1**] 11:42PM URINE HOURS-RANDOM UREA N-500 CREAT-92
SODIUM-LESS THAN POTASSIUM-36 CHLORIDE-LESS THAN
[**2185-8-1**] 11:42PM URINE OSMOLAL-294
[**2185-8-1**] 09:30PM GLUCOSE-104* UREA N-62* CREAT-2.4* SODIUM-133
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17
[**2185-8-1**] 09:30PM estGFR-Using this
[**2185-8-1**] 09:30PM CALCIUM-8.7 PHOSPHATE-5.4* MAGNESIUM-2.6
[**2185-8-1**] 09:30PM WBC-8.9 RBC-3.52* HGB-10.1* HCT-30.4* MCV-86
MCH-28.7 MCHC-33.2 RDW-14.2
[**2185-8-1**] 09:30PM NEUTS-76.8* LYMPHS-13.2* MONOS-7.9 EOS-1.9
BASOS-0.1
[**2185-8-1**] 09:30PM PLT COUNT-400
[**2185-8-1**] 09:30PM PT-23.1* PTT-35.1* INR(PT)-2.2*
Brief Hospital Course:
82 y/o female with CAD, paroxysmal atrial fibrillation who
presents from [**Hospital **] hospital after echo showed pericardial
effusion with signs of tamponade and clinically stable with
pulsus of 8.
ECHO showed: The left atrium is elongated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function appears preserved. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a large sized pericardial effusion. There is
right ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
Patient was monitored overnight. She was kept NPO. INR was
reversed with vitamin K, with INR 2.2 on transfer.
Anti-hypertensives and anticoagulants were held. All home meds
except simvastatin were held. Patient was given IVF since Urine
lytes showed pre-renal with Na < 10. She was also found to have
normocytic anemia, with Hct 28.7 on transfer.
Medications on Admission:
Simvastatin 80mg
Nifedipine 90mg
Aspirin 81mg
Isosorbide dinitrate 30mg
Lisinopril 40mg
NitroSL 0.4mcg PRN
Furosemide 20mg
Metoprolol 50mg
Coumadin 2.5mg
Colchicine 0.6mg TIDPRN
Discharge Medications:
TRANSFER MEDICATIONS:
Simvastatin 80 mg PO/NG DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
pericardial effusion
Discharge Condition:
alert and oriented
clinically stable
Discharge Instructions:
You were admitted for pericardial effusion. Your medications
were held and you were given IV fluids. You are being
transferred to another hospital for further care.
Followup Instructions:
Transfer to outside hospital. Will need f/u with PCP after
discharge
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4280, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4563
} | Medical Text: Unit No: [**Numeric Identifier 75145**]
Admission Date: [**2114-8-6**]
Discharge Date: [**2114-8-14**]
Date of Birth: [**2114-8-6**]
Sex: F
Service: NB
HISTORY: This is a full-term infant girl who was born on
[**2114-8-6**] via spontaneous vaginal delivery at
gestational age of 39 and 6/7 weeks to a 38-year-old, G4, P3
mother with prenatal labs notable for blood type B positive,
hepatitis B surface antigen negative, RPR nonreactive,
antibody negative, rubella immune. The mother was GBS
positive and received only an incomplete course of intrapartum
antibiotics prior to delivery, but no other sepsis risk
factors were present. The baby was delivered via vaginal
delivery, with Apgars of 9 and 9 and a birth weight of 3255
grams (7 pounds 2 ounces). The mother also has a family
history of lupus, and on a prior birth had once developed a
postpartum malar rash, but by her report she has remained [**Doctor First Name **]
negative and has never tested positive for lupus.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 7 pounds 2
ounces (3255 grams), length 19-3/4 inches, head circumference
34.5 cm. The baby was [**Name2 (NI) **], without any dysmorphism. There
were no skin lesions or rashes. The anterior fontanelle was
open and flat. She had a positive red reflex bilaterally. Her
palate was intact. Her lungs were clear to auscultation
bilaterally. Cardiovascular: S1, S2 within normal limits.
Regular rate and rhythm; no murmurs; 2+ femoral pulses. Her
abdomen was soft, nondistended and nontender, with positive
bowel sounds. No hepatosplenomegaly and no masses. She had
normal immature female genitalia. Her anus was patent. She
had no spinal defects or dimples. Her clavicles were intact,
and her hips were stable and symmetric. She had good tone and
positive Moro, grasp, and suck reflexes.
SUMMARY OF HOSPITAL COURSE BY ORGAN SYSTEM:
1. Cardiovascular - The baby remained hemodynamically
stable throughout her hospital admission.
2. Respiratory - The baby remained stable on room air
throughout her admission.
3. FEN/GI - The baby was exclusively breast fed by her
mother throughout her admission and posted excellent
weight gain, having regained her birth weight of 7
pounds 2 ounces by day of life 7. She was discharged on
day of life 8 with a weight of 7 pounds 3 ounces (3255
grams).
4. Infectious diseases - Because of the incomplete course
of intrapartum antibiotics that the mother received for
her GBS positive status, the baby was evaluated for an
occult bacteremia. Her CBC was reassuring, with a white
count of 19 and without a left shift. Blood cultures
were thereafter followed with no growth for over 48
hours. Antibiotics were never initiated.
5. Hematology - On day of life 2, at approximately 36 hours
of life, it was noted on routine bilirubin check the
baby had an indirect hyperbilirubinemia, with a total
bilirubin of 18.8 on [**8-8**]. As a result, triple
phototherapy was initiated that afternoon. Maternal blood
type A+/baby's blood type is O +/ direct coombs negative. Triple
phototherapy was
continued for a total of 3 additional days from [**8-8**] to [**8-11**], with serial checks of the baby's
bilirubin levels. By [**8-9**], after approximately 20
hours of phototherapy, the baby's bilirubin still
remained at 18.8; by [**8-10**] the bilirubin had lowered
to 15.8 after approximately 48 hours of phototherapy,
and on [**8-11**] the bilirubin was lowered to 13.4 after
approximately 60 hours of phototherapy. Phototherapy was
discontinued after approximately 72 hours in the evening
of [**8-11**]. However, after additional serial checks of
the bilirubin off of phototherapy, the bilirubin had
again risen to 15.8 on the evening of [**8-12**], and
double phototherapy was reinitiated and continued
for a total of an additional 24 hours until [**8-13**]
p.m., when the bilirubin had again been lowered to 13.4.
At this point, phototherapy was discontinued for the 2nd
time, and bilirubin was serially monitored until the
evening of [**8-14**], when it was 15.7 (approx 24 hrs off
phototherapy) at which time the baby was discharged home with a
plan for followup by her primary care physician as well
as hematology at [**Hospital3 1810**].
In addition to
evaluating any possible ABO incompatibility, the baby's
hematocrits and reticulocyte counts were checked
serially during her prolonged phototherapy course. On
[**8-9**] her hematocrit was 41 (compared to a
hematocrit of 44 on [**8-6**] during her sepsis
evaluation), and her reticulocyte count was 11.7. By [**8-10**], her hematocrit was 40.1
and her reticulocyte count was up to 12.6. At this
point, hematology was consulted for the mild anemia and
high reticulocyte count. The baby was evaluated by
[**Hospital3 1810**] Hematology, who noted on peripheral
blood smear the presence of polychromia, mild
anisocytosis, as well as some spherocytes. These
findings raised the possibility of a mild hereditary
spherocytosis. As a
result, an osmotic fragility test was drawn the morning
of [**8-14**] and is pending as of the date of discharge. the
baby's hct was 37 and retic was down to 3.7 on [**8-13**], prior to the
final discontinuation of phototherapy.
[**Hospital3 1810**] Hematology has concluded on the
basis of these findings and the relatively short
clinical course of the hyperbilirubinemia that responded
to phototherapy, that physiologic jaundice with a
component of high red blood cell turnover secondary to a
mild anemia is still the most likely etiology of the
baby's hyperbilirubinemia. However, in light of the
presence of spherocytes on her blood smear, a possible
diagnosis of a mild hereditary spherocytosis is still
being considered. Other mild bilirubin conjugation
defects such as [**Doctor Last Name 9376**] are also in the differential.
As a result, [**Hospital3 1810**] Hematology will should
follow up with the patient in their clinic within [**12-19**]
weeks after discharge with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62744**] at [**Telephone/Fax (1) 75146**].
6. Autoimmune - There is a maternal history of a lupus-like
malar rash in the setting of a family history of lupus.
However, as per the mother, the mother has always remained
[**Doctor First Name **] negative. In light of this history, and because there is no
history of maternal anti-
Ro or anti-[**Doctor First Name **] antibodies, the baby was deemed to be at
no risk for any lupus cardiomyopathy, and no
screening EKG was performed.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 18995**] in [**Location (un) 13588**],
[**State 350**]. Telephone [**Telephone/Fax (1) 40227**].
CARE RECOMMENDATIONS:
1. The baby should p.o. breast feed ad lib.
2. No medications.
3. State newborn screen was sent on [**2114-8-8**].
4. [**Doctor Last Name **] hearing screen passed bilaterally.
5. Baby received the Hep-B vaccine on [**2114-8-7**].
6. Immunizations recommended: 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.
7. Follow-up appointments: The patient should be seen by
her primary pediatrician within 1 day after discharge,
and the baby should be seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62744**] at
[**Hospital3 1810**] Hematology within 1-2 weeks after
discharge, telephone [**Telephone/Fax (1) 47801**].
DISCHARGE DIAGNOSIS:
1. Full-term appropriate for gestational age infant girl.
2. Prolonged jaundice with reticulocytosis and mild anemia,
status post phototherapy x96 hours. The baby is to be
followed up with [**Hospital3 1810**] Hematology for a
possible diagnosis of hereditary spherocytosis pending
results of osmotic fragility test.
3. Maternal history of lupus, but no signs of neonatal lupus.
4. Sepsis evaluation without antibiotics.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 71194**]
Dictated By:[**Last Name (NamePattern1) 72910**]
MEDQUIST36
D: [**2114-8-14**] 14:39:41
T: [**2114-8-14**] 16:01:46
Job#: [**Job Number 75147**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4564
} | Medical Text: Admission Date: [**2157-11-16**] Discharge Date: [**2157-12-5**]
Date of Birth: [**2084-6-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Anal squamous cell carcinoma
Major Surgical or Invasive Procedure:
Abdominal peroneal resection, gracilus flap closure
History of Present Illness:
This is a 73 year old man with hx of HIV/AIDS who presents with
extensive squamous cell anal cancer who presents for
resection/[**Month (only) **]
Past Medical History:
1) HIV/AIDS
2) DM Type II
Social History:
Pt lives with partner in [**Name (NI) 3615**], but they are staying in
[**Hospital1 8**] as he is getting radiation therapy. Homosexual male.
Denies IVDU, EtOH, Tob.
Family History:
Non contributory
Physical Exam:
126/68 72 97.0 18 99%ra
NAD
MMM
CTA-B
RRR
soft, non-tender abdomen
rectal: some tenderness
Pertinent Results:
[**2157-11-16**] 09:25PM GLUCOSE-130* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2157-11-16**] 09:25PM ALT(SGPT)-17 AST(SGOT)-26 ALK PHOS-64 TOT
BILI-3.9*
[**2157-11-16**] 09:25PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-5.5*#
MAGNESIUM-1.5*
[**2157-11-16**] 09:25PM WBC-5.9# RBC-2.91* HGB-12.4* HCT-33.3*
MCV-114* MCH-42.7* MCHC-37.3* RDW-15.0
[**2157-11-16**] 06:25PM TYPE-ART PO2-105 PCO2-37 PH-7.40 TOTAL CO2-24
BASE XS-0 COMMENTS-NOT SPECIF
[**2157-11-16**] 06:25PM GLUCOSE-132* LACTATE-1.3 NA+-136 K+-4.0
CL--108
[**2157-11-16**] 06:25PM HGB-10.8* calcHCT-32
[**2157-11-16**] 06:25PM freeCa-1.21
[**2157-11-16**] 02:26PM TYPE-ART PO2-176* PCO2-36 PH-7.43 TOTAL
CO2-25 BASE XS-0
[**2157-11-16**] 02:26PM HGB-12.0* calcHCT-36 O2 SAT-98
[**2157-11-16**] 12:00PM freeCa-1.20
[**2157-11-16**] 10:12AM freeCa-1.19
Brief Hospital Course:
After uneventful [**Month (only) **] and gracilis flap closure by plastics, the
patient kept in the pacu overnight, he was kept intubated post
op, but extubeabted next AM. He was kept on a kinair mattress
with no leg abduction or sitting. He was kept on Vanco and
Zosyn as perioperative antibiotics. HIV meds were restarted on
POD 3. He was transfered to the T/SICU due to nausea/vomiting
with hypoxia and tachypnea. He did well in the unit, his
hypoxia resolved and after two days in the unit he was
transfered back to the floor. Enterostomal therapy was
consulted to teach and care for his new ostomy, this went well
without complications. On [**11-22**] JP #1 was discontinued. NG
tube was d/c'ed on [**11-22**] as well. Foley was d/c'ed on day of
transfer to rehab. He went to rehab without issue
Medications on Admission:
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig:
One (1) Inhalation Q6H (every 6 hours).
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qAM ().
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
11. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QPM (once a day (in the evening)).
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection [**Hospital1 **] (2 times a day).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to buttocks region.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qAM ().
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
11. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QPM (once a day (in the evening)).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
14. Morphine Sulfate 8 mg/mL Syringe Sig: 1-5mg Injection Q4H
(every 4 hours) as needed for breakthrough pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Anal squamous cell carcinoma
Diabetes
HIV/AIDS
Discharge Condition:
good
Discharge Instructions:
Notify MD if you experience incresing pain, fever > 101.4,
bleeding or other concering signs. Resume taking all of your
pre procedure medications
Followup Instructions:
in [**1-11**] weeks with Dr. [**Last Name (STitle) **], call her office for an
appointment
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2157-11-24**]
ICD9 Codes: 5845, 2760, 2765, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4565
} | Medical Text: Admission Date: [**2140-11-14**] Discharge Date: [**2140-11-17**]
Date of Birth: [**2098-9-9**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Progressive dyspnea
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known lastname 39729**] is a 42-year-old woman with history of chronic
mesenteric ischemia s/p R hemicolectomy/[**Female First Name (un) 899**] reimplantation in
[**6-9**], HTN, hypercholesterolemia who presented to the ED with
intermittent, exertional SOB. Patient reports further worsening
in breathing status over past several days, with milder exertion
required to elicit shortness of breath; associated with
non-productive cough, generalized weakness, and dizziness. No
chest pain, fevers, chills, vomiting, black stool. She does
intermittently pass blood clots in her stool which was thought
to be due to internal hemorrhoids. No syncopal episodes. LMP
earlier this month, no heavy or unusual bleeding. Given
persistence of symptoms, she sought evaluation in the ED.
.
In the Emergency Department, initial VS were T 98.3; BP 120/52;
HR 93; RR 15; O2 98%RA. She received a CTA to rule out PE given
elevated d-dimer, which was negative. Hct results then returned
at 19.0, and she received 2 units PRBCs. She also received 40mEq
potassium and 1L NS IV bolus given low BP in 90s.
.
On arrival to the [**Hospital Unit Name 153**], patient reported that she was feeling
much better. Denied chest pain or shortness of breath.
Pan-review of systems negative including cardiac, GI and GU.
Past Medical History:
-HTN
-Hyperlipidemia
-Chronic fatigue
-Chronic headaches
-Fibromyalgia
-Depression/Anxiety
-Talus fracture
-Cervical cancer
-GERD
-Hydronephrosis
-Mild COPD
-Chronic mesenteric ischemia - known occlusion of SMA and
celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by vascular surgery
-Recent admission [**7-9**] for ? TIA - foudn to have microvascular
infarcts on MRI and HTN.
PAST SURGICAL HISTORY
- Appendectomy [**2131**]
- [**6-3**]: ileocecectomy without re-[**Last Name (LF) 39727**], [**First Name3 (LF) 899**] re-implantation
- [**6-5**]: SBR, R colectomy, ileocolic reanastamosis
- [**6-28**]: ERCP-choledochal-duodenal fistula proximal to major
papillary opening
Social History:
Smoking history, no current alcohol use, but did use alcohol in
past
Family History:
Mother and aunt with coronary artery disease and carotid
disease. Both parents died of lung cancer, mother at age 73,
father at age 68.
Physical Exam:
VS: T 98.6; BP 111/52; HR 72; RR 12; O2 100% RA
GEN: Pleasant middle aged woman in NAD, comfortable
HEENT: anicteric sclerae. MMM. OP clear.
NECK: No JVD. Supple, FROM
HEART: S1S2 RRR. Mid-peaking systolic murmur
LUNGS: CTA B/L
ABD: well-healed midline surgical scar. soft, NT/ND. + BS. No
HSM
EXT: No C/C/E. 2+ DP and PT bilaterally
NEURO: AO x 3. No focal exam deficits. CN II-XII intact grossly.
Pertinent Results:
EGD with small bowel enteroscopy on [**2140-11-16**]:
Ulcers in the antrum (biopsy)
Normal mucosa in the duodenum
Normal mucosa in the jejunum
Brief Hospital Course:
#Anemia/Dyspnea/Lightheadedness - Symptoms attributed to anemia
from GI bleed given guiac positive stools. Pt's crit bumped
appropriately to 3U PRBC, and was kept above 28 given her
history of vascular disease. Pt was on Plavix because of her
[**Female First Name (un) 899**] stent, which was initially held in the context of GI
bleeding, but restarted on HD2. GI was consulted who proceeded
to perform a small bowel enteroscopy on [**11-16**] which revealed
oozing ulcers in the antrum of the stomach. Punch biopsies were
taken at that time to assess for H. Pylori which on discharge
are pending. Their recomendations were to start Prilosec 40 mf
po BID.
#Peptic Ulcer Disease: Hematocrit stabilized, ulcers found in
antrum of stomache with signs of recent bleeding. GI suggests
[**Hospital1 **] Prilosec. Dr. [**Name (NI) 3407**], pts vascular surgeon was contact[**Name (NI) **]
re: anti-platelet therapy. He emailed that he only would ask
for aspirin daily as tolerated, and does not feel Plavix is
necessary from his standpoint. In the past, the neurology team
had started pt on Plavix and in their notes had referred to it's
benefits in setting of pt's PVD. Pt discharged and told to
continue full dose aspirin and to discontinue plavix. Please
have hct rechecked on [**2140-11-22**] when pt visits PCP [**Name Initial (PRE) 3726**].
#EKG Changes - Patient with inferolateral downsloping ST changes
in setting of Hct 19.0, that were new compared to [**2140-7-3**]
study. Pt was started on ASA 325. Pt denied chest pain and ruled
out for MI by enzymes x3. Cardiology was consulted who felt
that these changes were likely demand ischemia in the setting of
anemia, and their interpretation of the ECGs indicated that they
felt that the new ST changes were resolving with transfusion.
TTE showed no wall motion abnormalities. Cardiology's
recomendation was to follow up in clinic for assessment and
workup of likely CAD given her extensive history of vascular
disease. Follow up [**Year (4 digits) 1988**] with Dr. [**Last Name (STitle) 73**] in 12/[**2140**].
#Hypotension - Pt was transiently hypotensive to the 90's in the
ED for which she was fluid resucitated with 1L of NS. Her
anti-hypertension medications were held in this setting. She
remained stable through remainder of hospital course with SBP in
the 90s. She was told to continue beta blocker (given concern
for cardiac ischemia) but to discontinue HCTZ and verapamil
until re-assessed by PCP.
#Sore Throat - Pt reported having had a sore throat for several
months at this admission, which was exacerbated by swallowing
and occassionally impaired her breathing. ENT was consulted who
gave the diagnosis of laryngopharyngeal reflux disease, and
recomended high dose PPI and follow up in [**Hospital **] clinic in [**4-8**]
weeks.
#Chronic Mesenteric Ischemia - Pt reported having no acute
abdominal pain since her surgery in [**Month (only) **]. She was on plavix due
to the [**Female First Name (un) 899**] stent which was placed. The plavix was initially
held while an acute GI bleed was ruled out, but then restarted
when the problem appeared to be more chronic. Vascular was
consulted, and they had no new recomendations at this time. Dr.
[**Last Name (STitle) 3407**] emailed that pt does not need Plavix at this time.
#Irritable Bowel Syndrome - Continued dicyclomine, no changes
made.
#Hyperlipidemia - Continued Zocor, pt had good lipid levels in
[**Month (only) 205**].
#Depression and Anxiety - Continued fluoxitine but held
nortriptyline based on cardiology recomendation that
nortriptyline can increase orthostatic hypotension. Pt will
follow up with her PCP in one week to determine whether she
needs to restart nortriptyline.
Medications on Admission:
dicyclomine 2 caps TID
fluoxetine 10mg qd
nortriptyline 10mg qd
PLAVIX 75mg qd
ranitidine 150mg [**Hospital1 **]
Colace [**Hospital1 **]
HCTZ 25mg qd
metoprolol 25mg [**Hospital1 **]
verapamil 80mg tid
simvastatin 20mg qd
Discharge Medications:
1. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headaches.
Disp:*50 Tablet(s)* Refills:*0*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*0*
9. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Outpatient Lab Work
Hct checked on [**2140-11-22**] at Dr.[**Name (NI) 12522**] office
Discharge Disposition:
Home
Discharge Diagnosis:
peptic ulcer disease
Discharge Condition:
Good po intake, hct stable for 3 days.
Discharge Instructions:
Please follow up with your uncoming appointments with Dr. [**Last Name (STitle) 3407**]
and Dr. [**Last Name (STitle) 2161**]. Call your primary care doctor, Dr. [**Last Name (STitle) 2161**], or
return to ER with increased blood in bowel movements, abdominal
pain, chest pain, shortness of breath, or other concerning
symptoms. Your medication list has been rechecked and is
correct.
Please be sure to ask Dr. [**Last Name (STitle) 7790**] about whether or not to
continue Nortryptiline.
Followup Instructions:
1)Dr. [**Last Name (STitle) 3407**]: VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-11-22**]
8:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-11-22**]
9:00
2)Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2140-11-22**] 3:30
3) Dr. [**Last Name (STitle) 2161**] [**2140-12-5**] at 11:00am at the [**Hospital3 **] [**Location (un) 86**] site
[**Hospital Unit Name 1825**] [**Hospital Ward Name **].
Also follow up with cardiology and ENT Dr. [**Last Name (STitle) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2140-11-17**]
ICD9 Codes: 496, 2768, 4240, 2724, 4019, 2720, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4566
} | Medical Text: Admission Date: [**2124-9-12**] Discharge Date: [**2124-10-17**]
Date of Birth: [**2076-11-20**] Sex: M
Service: ORTHO
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
47 year old M pedestrian struck by a car on [**2124-9-12**] sustaining
multiple pelvic fractures, left leg fractures, traumatic bladder
and left ureter injuries and nerologic defecits in his left leg
and foot.
Major Surgical or Invasive Procedure:
ORIF left SI joint
Symphysis plate
Left IM rod to Left tibia/fibula fracture
External Fixator to Pelvis
U/S guided tap of pelvic fluid collection
PLEASE: see operative notes for full detail of all surgical
procedures.
History of Present Illness:
48 M s/p pedestrian vs. auto on [**2124-9-12**], high speed and thrown 10
feet, + loss of consciousness, brought in to ER hemodynamically
unstable, with SBP's in the 70's, pelvic instability noted and
his pelvis was wrapped in a sheet, left lower extremity was
splinted. He had an open book pelvic fracture on x-ray, an
obvious closed left lower leg fracture/deformity, pulses intact,
he had left SI joint disruption, retroperitoneal hematomas and a
bladder injury/leak noted on CT-abdomen, left lower extremity
showed a comminuted tib/fibula fracture, and he was sent to
angiography but no bleeding vessels were found in the pelvis or
the leg, he did require approx 5 units of red cells during this
resuscitation. Patient to O.R. for pelvic Ex-Fix, and left
Tib/fib repair same night.
Past Medical History:
Asthma
Hypertension
Medicines include albuterol inhaler, flovent, HCTZ 25 QD
All- NKDA
Social History:
Lives in [**Name (NI) 669**], wife and 5 children. No alcohol tobacco or
IVDU reported.
Family History:
+gallstones
otherwise noncontributory
Physical Exam:
In trauma bay:
BP- 96/palp 84 18 99% room air
AAO X 3. GCS 15.
Neck-trach midline
HEENT- PERRL, EOMI, Tm's clear
Pulm- CTA bilaterally, no crepitus, no obvious rib fractures
Abd- soft, tender and mildly distended
FAST exam negative.
Pelvis- grossly unstable, wrapped in sheet
GU- no penile bleeding noted
Ext- Left leg obvious deformity and externally rotated, closed,
doppler pulse bilaterally biphasic.
Rectal- guaiac negative, normal tone, no gross bleeding
Pertinent Results:
[**2124-9-15**] 02:13AM BLOOD WBC-7.5 RBC-2.82* Hgb-8.8* Hct-24.3*
MCV-86 MCH-31.3 MCHC-36.2* RDW-14.0 Plt Ct-55*
[**2124-9-13**] 01:45PM BLOOD Neuts-64 Bands-23* Lymphs-12* Monos-0
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2124-9-12**] 07:16PM BLOOD UreaN-22* Creat-1.6*
[**2124-10-3**] 08:26AM BLOOD ALT-144* AST-58* LD(LDH)-316*
AlkPhos-246* Amylase-64 TotBili-7.2* DirBili-5.1* IndBili-2.1
[**2124-9-12**] 07:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Pertinent XRAYS/CTs on initial workup:
Pelvis XRAY- wide open book pelvic fracture, symphysis
diasthesis
Abd-CT #1- ?bladder rupture and retroperitoneal leak, left SI
joint disruption and large hematoma formation.
Head CT- negative.
C-spine films negative.
Tibia/fibula films- comminuted fracture evident.
Thoracic/lumbar/sacral spine films negative.
Pertinent Studies during hospital course:
CT-abdomen [**10-6**]:
There is a fluid collection within the anterior pelvic wall,
located deep to
the surgical sutures. The fluid collection extends anterior to
the pubic
symphysis and extends posteriorly along the right pelvic floor.
This fluid
collection measures 3.8 x 7.2 cm in greatest cross sectional
diameter, at the
level of the pubic symphysis. The inferior most portion of the
fluid
collection is not included on this series. There is gas within
the collection
and there is rim enhancement around the fluid.
([**10-8**]) U/S guided aspiration of the pelvic fluid collection
showed:
WBC [**Numeric Identifier 16351**], RBC [**Numeric Identifier **], Creatinine 2.6, cultures grew +MRSA.
Previous Blood culture on [**9-25**]/8 bottles grew +MRSA.
I.D. consult obtained. Recommended a 2 week vancomycin course
with levels checked for peak/trough. Also levofloxacin for 2
weeks, 500 mg a day.
CT-abdomen [**10-14**]:
High attenuation material tracking around the anterior pelvic
fluid
collection and left pelvic soft tissues. This is concerning
for
extravasatation, possibly from a urinary source.
Brief Hospital Course:
As above, after the patients fractures and wounds were
stabilized surgically by multiple operations and ORIF's, and
wound vac placement at the left pelvic wound operative site, it
was noted that he was developing an ileus. An abdominal CT
confirmed this and showed no signs of obstruction, but did
elucidate the pelvic fluid collection which was of concern. He
had low-grade temps at this point as well. The concern was for
the ileus, and general surgery was consulted for management, and
an NG tube was placed for approx 6 days. The low-grade temps
and pelvic fluid collection, and high bilirubin and hepatic
enzyme levels concerned the ortho team and we consulted
infectious disease and medicine. Urology was also re-consulted
for question of a bladder leak into the pelvis when the
creatinine from the fluid came back elevated at 2.6. They
recommended leaving the foley in for several weeks and repeating
the cystogram at that time. The patients ileus was very
pronounced and eventually he required TPN for approx 1 week.
His diet was SLOWLY advanced from clears to full house diet and
he began having bowel movements and improvement in his abdominal
distension. His pelvic fluid collection was aspirated via
ultrasound and the cultures grew MRSA. He did not spike fever
after this point, and no further blood cultures grew any
bacteria. His workup for hepatitis was negative, and his
bilirubin levels returned to [**Location 213**]. His wound VAC was D/C'd
and he was continued on Wet-to-dry dressings to the pelvic
wounds which were granulating in well. His left lower extremity
never recovered from the initial foot drop that was noted by the
ortho team. Physical therapy worked with the patient as well,
and he was ambulating with assistance. His foley remains in.
He has a Right PICC line for the antibiotics. He was continued
on vancomycin and levofloxacin during this time, but the vanco
levels were subtherapeutic for several days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple pelvic fractures/open book pelvis
Traumatic bladder injury and leaking Left ureter
Pelvic Urinoma
MRSA infection
Ileus
Left leg foot drop/neuropathy
Discharge Condition:
FAIR
Discharge Instructions:
Continue your physical therapy exercises. Continue your
medicines as previosuly.
Followup Instructions:
Please followup with Dr. [**First Name (STitle) 1022**] and Dr. [**Last Name (STitle) 9694**] in the orthopedics
clinic in [**2-11**] weeks for assessment. Call Dr.[**Name (NI) 9695**] office
[**Telephone/Fax (1) 94135**], and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] at [**Telephone/Fax (1) 7807**].
Please followup in the Infectious Disease Clinic within [**2-11**]
weeks.
Please followup with the urology clinic in [**2-11**] weeks for
reassessment of your bladder and ureter and catheter removal.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**]
Completed by:[**2124-10-17**]
ICD9 Codes: 2851, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4567
} | Medical Text: Admission Date: [**2156-12-23**] Discharge Date: [**2156-12-25**]
Date of Birth: [**2084-5-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 y/o F with infiltrating ductal carcinoma s/p lumpectomy and
CTX with adrimycin/ cytoxin/ taxol currently on herceptin who
presents with fever, cystitis and transient hypotension.
.
The patient complained of suprapubic tenderness and increased
urgency x 10 days. She was seen by her gynecologist yesterday
who diagnosed a UTI and prescribed macrobid. This morning she
complained of nausea, spiked a fever to 102 and called her
oncologist who changed her antibiotics to ciprofloxacin. She
proceeded to have a syncopal episode lasting approximately 1 min
after a loose bowel movement. This was witnessed by her husband,
who noted no jerking movements, tongue biting or incontinence.
Of note, she does have a history of syncopal episodes while on
adriamycin in the setting of profound anemia. She has had
several MUGA scans which have reportedly been normal.
.
In the ED, initial VS: T 99.1 P 89 BP 95/55 (normal BP in 150s)
RR 14 SaO2 98%. Initial labs were notable for a leukocytosis to
14.9 and lactate of 1.1. CXR was normal and U/A was significant
for microscopic hematuria and [**4-2**] WBC. She was given IV
ciprofloxacin and 1L NS bolus x 3. As BP did not rise
significantly, antibiotic coverage was broadened to cefepime.
Due to concern for possible septic shock, patient transferred to
[**Hospital Unit Name 153**] for closer monitoring.
.
ROS: denies any night sweats, weight loss, headache, change in
vision, dysphagia, chest discomfort, palpitations, SOB,
abdominal pain, N/V, diarrhea, hematuria, rashes or other other
complaints.
Past Medical History:
1. infiltrating ductal carcinoma s/p lumpectomy and CTX
- dx in [**3-10**] with 1.4 cm grade 2 infiltrating ductal cancer, ER
positive, low PR positive, HER-2/neu positive, +1 LN
- s/p left partial mastectomy and XRT
- s/p chemotherapy with cytoxan and adriamycin followed by
herceptin and taxol. Taxol was stopped 3 weeks early due to
neuropathy
- currently on herceptin
- planned XRT for [**12-30**]. HL
3. HTN
4. anxiety disorder
Social History:
Married with 2 children, her husband is a retired neurologist.
- tobacco: remote history of tobacco use, 10 pack yr history
- ETOH: approx 6 drinks/ week
- illicits: denies
Family History:
Positive for breast cancer in a paternal cousin in the 70s.
Sister with [**Name (NI) 27210**] Syndrome. Father died of complications of
sepsis and heart disease.
Physical Exam:
VS: T: afebrile BP: 119/58 HR: 70 RR: 21 SaO2: 98% RA
GEN: [**Last Name (un) 664**] female appearring younger than stated age
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy; JVD at base of neck
RESP: bibasilar crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no ulcerations
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated, position sense
intact. No pass-pointing on finger to nose.
Pertinent Results:
EKG [**2156-12-23**]-
Sinus rhythm. Prolonged P-R interval. Compared to the previous
tracing
of [**2156-3-19**] the P-R interval has increased.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 208 94 376/419 58 62 31
.
CXR-FINDINGS: Port-A-Cath is in stable course and position from
a right internal. jugular approach with the distal tip of the
catheter situated near the superior cavoatrial junction. No
consolidation or edema is evident. The mediastinum is
unremarkable. The cardiac silhouette is within normal limits for
size. Subsegmental atelectasis is noted in the retrocardiac left
lower lobe. The cardiac silhouette remains borderline enlarged,
but stable. Subtle blunting of the right costophrenic angle may
indicate a small pleural effusion. The osseous structures are
unremarkable.
.
IMPRESSION: Interval development of a small right pleural
effusion with
associated atelectasis. There is also a new subsegmental left
lower lobe
atelectasis. Otherwise, no acute pulmonary process noted.
[**2156-12-25**] 06:35AM BLOOD WBC-5.3 RBC-3.18* Hgb-9.8* Hct-30.4*
MCV-96 MCH-30.8 MCHC-32.3 RDW-14.3 Plt Ct-192
[**2156-12-23**] 02:05PM BLOOD WBC-14.9*# RBC-3.45* Hgb-10.9* Hct-31.8*
MCV-92 MCH-31.6 MCHC-34.3 RDW-14.4 Plt Ct-196
[**2156-12-23**] 02:05PM BLOOD Neuts-91.7* Lymphs-3.1* Monos-2.8 Eos-2.2
Baso-0.2
[**2156-12-25**] 06:35AM BLOOD Plt Ct-192
[**2156-12-24**] 04:30AM BLOOD Plt Ct-168
[**2156-12-23**] 02:05PM BLOOD Plt Ct-196
[**2156-12-23**] 02:05PM BLOOD PT-12.8 PTT-22.7 INR(PT)-1.1
[**2156-12-25**] 06:35AM BLOOD Glucose-93 UreaN-13 Creat-0.8 Na-142
K-3.7 Cl-107 HCO3-28 AnGap-11
[**2156-12-24**] 04:30AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-142
K-3.7 Cl-111* HCO3-26 AnGap-9
[**2156-12-23**] 02:05PM BLOOD Glucose-153* UreaN-22* Creat-1.1 Na-136
K-4.1 Cl-100 HCO3-28 AnGap-12
[**2156-12-23**] 02:05PM BLOOD CK(CPK)-31
[**2156-12-24**] 04:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2156-12-23**] 02:05PM BLOOD cTropnT-<0.01
[**2156-12-25**] 06:35AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
[**2156-12-24**] 04:30AM BLOOD Calcium-8.7 Iron-20*
[**2156-12-23**] 02:05PM BLOOD Calcium-9.8 Phos-3.4 Mg-1.7
[**2156-12-24**] 04:30AM BLOOD calTIBC-207* Ferritn-276* TRF-159*
[**2156-12-23**] 02:05PM BLOOD GreenHd-HOLD
[**2156-12-23**] 02:51PM BLOOD Lactate-1.1
.
[**2156-4-8**] echo Last echo-The left atrium is normal in 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) 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 mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
MPRESSION: Normal left and right ventricular function. Normal
valvular function. Mild pulmonary hypertension.
Brief Hospital Course:
72 y/o F with infiltrating ductal carcinoma s/p lumpectomy and
chemotherapy currently on herceptin who presents with fever,
symptoms of cystitis and syncopal episode s/p transient
hypotension.
.
# Hypotension: She had clinical symptoms of a UTI/cystitis that
was untreated for several days-possibly weeks prior to treatment
with antibiotics. She presented to outpatient GYN [**12-22**] and was
given macrobid. She continued with symptoms, and her outpatient
oncologist changed her antibiotic to Cipro. She arrived in the
ED on [**12-23**] with a SBP 95 (Normal 150's) and received 3L NS, and
IV cipro and cefepime with concern for urosepsis,
pyelonephritis, and volume depletion. However, pt remained
afebrile, lactate normal, and did not have any subsequent
episodes making sepsis unlikely. On arrival to the ICU/floor
she was normotensive with SBPs in the 120's and did not have any
further episodes of hypotension. The etiology of her
hypotension was thought to be secondary to volume depletion in
the setting of decreased PO intake for the past few days. Pt's
orthostatics were negative. However, this was after the infusion
of IVF. Pt did not display signs of symptoms of PE (no
tachycardia/hypoxia/CP) or MI (negative troponins, EKG without
signs of acute ischemia) nor were there signs of arrhythmia. Pt
was encouraged to increase her PO intake of fluids after
discharge.
.
# Syncope: This was likely vasovagal pt on toilet at the time
and/or due orthostatic hypotension give poor PO intake. Tere was
no evidence of seizure activity (this episode was witnessed by
the patient's husband who is a neurologist). There was no
suggestion of cardiac cause or PE (no SOB/hypoxia/CP/EKG normal
and last echo was normal). She was fluid resuscitated without
any additional symptoms. Pt did receive adriamycin, but last
echo and MUGA scan (per report) were negative.
.
# Leukocytosis/acute complicated cystitis-Pt with
dysuria/urinary urgency and suprapubic tenderness for a few
weeks prior to admission and recent fever. Pt's urine culture
from her gynecologist's office grew mixed genital flora. Her
blood cultures and urine cultures this admission have shown no
growth to date. However, this was after the initiation of
antibiotics in the outpatient setting. Pt aware that her
cultures are still pending at the time of discharge. However,
she is clinically much improved. Pt will be treated with 14 days
of cipro for acute complicated cystitis. She did not report any
back or flank pain nor did she have CVA tenderness suggestive of
pyelonephritis. Pt has an appointment with her gyn on monday.
She was advised to keep this appointment.
.
#small R.sided pleural effusion associated with atelectasis-This
was noted on chest x-ray. Pt did not report any dyspnea, SOB,
chest pain and satted well on room air. Pt does have a history
of breast cancer but there was no known mass reported on CXR.
This is likely related to atelecatasis but should be followed
closely by her PCP [**Name Initial (PRE) **]/or oncologist to decide if further work
up and/or imaging is indicated.
.
#anemia-normocytic, iron studies show anemia of chronic disease.
HCT's were trended and remained stable. Discharge HCT 30.4.
Stools were ordered for guaiac. Pt should have this followed in
the outpatient setting and if indicated, she should consider
need for colonoscopy.
.
#infiltrating ductal carcinoma s/p lumpectomy and
chemotherapy-pt finished her last chemo session ~3weeks ago. She
was not neutrapenic. She is planning on beginning radiation
therapy in [**1-7**]. Pt was advised to keep her already scheduled
follow up appointments in the next coming weeks.
.
#hyperlipidemia-continued on statin.
.
#depression-no signs of SI, continued on celexa.
Medications on Admission:
- celexa 10mg daily
- lipitor 20mg daily
- ASA 81mg daily
- multivitamin
Discharge Medications:
1. Celexa 10 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. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
acute complicated cystitis
fever
hypotension
.
Minor: breast cancer s/p chemotherapy
anemia depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with urinary urgency, fever, low blood
pressure, and reports of passing out at home. You were initially
admitted to the ICU for concerns of a severe infection given the
low blood pressure. You did not have any additional low blood
pressures or fever during the admission. Your episode of passing
out was likely due to dehydration and infection. In the ICU you
were given broad coverage antibiotics and this was changed over
to ciprofloxacin for cystitis (infection of the bladder and
urinary tract). You were given IV fluids. Your symptoms
improved. Your urine and blood cultures are still pending at the
time of discharge and will need to be followed up by your PCP.
.
Please be sure to stay well hydrated and drink plenty of fluids.
Please take a few days to rest after discharge.
.
Medication changes:
1.start taking ciprofloxacin 500mg [**Hospital1 **] (twice a day) for 13 more
days to complete a 14 day course.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please be sure to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] at
[**Telephone/Fax (1) 7318**] to schedule a follow up appointment within 1 week
of discharge.
Please keep your already schedule appointment with your
gynecologist Dr. [**Last Name (STitle) 103348**] on Monday [**12-27**] [**Telephone/Fax (1) 103349**]
Please keep your oncology appointments as per below
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2156-12-29**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2157-1-19**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2157-2-9**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4568
} | Medical Text: Admission Date: [**2109-2-24**] Discharge Date: [**2109-2-26**]
Date of Birth: [**2067-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest Pain, STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
The patient is a 41 M with a history of hyperlipidemia, family
history of early MI and tobacco abuse who presented to [**Hospital **] at midnight with chest pain since 9pm, found to have
[**Hospital **] transferred to [**Hospital1 18**] for cardiac catherization, now s/p
stenting to proximal RCA.
At 9pm this evening the patient developed pain at the center of
his chest while sitting watchign TV, no exertion. soom after, he
felt tingling in his left hand. He had associated shortness of
breath and felt warm and sweaty, although had no actual sweat.
He also reports feeling lightheaded. The symptoms resolved when
sitting still, but would come back with even minimal exertion.
THe patient left his house at 1130pm, and was at [**Location (un) **] by
midnight. The patient reports having had chest pain prior, but
not cardiac.
In the cath lab, the patient became bradycardic, but responed
well to 1mg of atropine. He initially had a temporary pacer wire
inserted, but this was discontinued after revasculization. The
patients blood pressure was initially in the 170s systolics but
after recieving numerous nicardipine boluses, was down to 110s.
The patient was awake and alert throughout the case. Wedge
pressure 15, RA mean 15, suggestive or RV infarct.
.
On floor, patient was resting comfortably with no complaints.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems as above.
.
Cardiac review of systems is notable for chest pain, dyspnea on
exertion, negative for paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Hyperlipidemia: no meds x 2 years for this.
Social History:
The patient reports smoking since age 7, [**Date range (1) 8642**] packs/day. The
patient smoked last cigarette at midnight before entering
hospital. the patient drinks very rarely. EH works as technician
buildigs machinery for government, gets exercise at work. HE is
married with 4 kids and one grandchild. He lives with his wife
in [**Name (NI) **].
Family History:
family history of early MI. FAther died age 52 of MI, paternal
uncles died at 47 and 41 of MIs, he had 2 uncles who died early,
4 days and age 7. Mother had first MI age 51, and died of MI age
75. Family history of HTN on fathers side
Physical Exam:
VS: HR 65, BP 140/80, 96% on 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with non elevated JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. right [**Last Name (un) **] closed with angioseal, no
bruits, no hematoma
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ PT 2+
Left: Carotid 2+ Femoral 2+ PT 2+
Pertinent Results:
[**2109-2-24**]
Na 139 / K 3.9 / Cl 107 / CO2 22 / BUN 13 / Cr .9 / BG 105
Mg 2
TChol 232 / Triglycerides 184 / HDL 33 / LDL 162
.
Cardiac Enzyme Trends
CK 254 --> 1206 -->
MB 14 --> 100 -->
Trop T .14
.
STUDIES:
[**2109-2-24**] - Cardiac Catheterization - . . .
.
[**2109-2-24**] - ECG - HR 77, ST elevations in II, III, aVF, V1, v3,
depression in I and AVL
Brief Hospital Course:
STUDIES:
TTE [**2109-2-25**]:
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with hypokinesis of the basal
to mid inferior septum and inferior wall.. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. EF 40-45%
IMPRESSION: Regional LV systolic dysfunction and global RV
systolic dysfunction consistent with RCA ischemia/infarction. No
pathologic valvular abnormality seen.
HOSPITAL COURSE:
STEMI/RV infarct: Risk factors include hyperlipidemia, tobacco
abuse, family history early MI. Patient with RV infarct, so
preload dependent. Temporarily bradycardic in cath lab,
responded to atropine. Started Plavix 75mg, Atorvastatin 80mg,
Aspirin 325mg. Also started beta blocker low dose 12.5mg [**Hospital1 **],
but with caution given prox RCA occlusion and bradycardia during
cath. Lipid panel: Cholest 232 Triglyc 184 HDL33 LDLcalc 162.
Continued aggrenox x12 hours post cath. Post cath check showed
small 2inch by 2 inch hematoma. Hct was stable. Echo showed
reduced LVEF (40%) and HK of inferiod wall consistent with RCA
infarct as evidenced on the EKGs. CKs peaked at 1559 and then
trended down. The patient remained pain-free and hemodynamically
stable after cath and was transferred to the regular medical
floor.
Transaminitis: Patient had elevated LFTs to 200s range at OSH.
On recheck here they were trending down. Hepatitis panel showed
was negative. As INR was 1.2,likely acute insult in setting of
MI but with normal liver functional capacity.
Smoking Cessation: pt counseled on smoking cessation while
hospitalized. He refused any nicotine replacement of medicines
as he felt it would be easy to quit and he would not have any
withdrawal symptoms.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking this drug for one year.
Disp:*30 Tablet(s)* Refills:*11*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. STEMI
2. Coronary Artery Disease
3. Hyperlipidemia
4. Transaminitis
PRIMARY DIAGNOSIS:
1. STEMI
2. Coronary Artery Disease
3. Hyperlipidemia
4. Transaminitis
Discharge Condition:
Stable. Patient is tolerating oral intake, ambulating, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital with chest pain and were found
to have a heart attack. You underwent a cardiac catheterization
and were found to have a blockage in one of the major arteries
that supplies blood to your heart. You had a stent placed to
keep that artery open. You were started on several new
medications, and it will be important to continue to take these
medications. It will be especially important for you to continue
taking aspirin and plavix every day for one year, as these
medications help keep your stent open.
Tests of your liver were mildly abnormal and trended back
toward normal while you were hospitalized. Hepatitis tests are
pending at the timeof discharge. Dr. [**Last Name (STitle) 11493**] can access them and
discuss them with you at your appt. Your PCP should test your
liver again when you see him next to ensure they have continued
to trend down.
.
We have made the following changes to your medications:
- aspirin - please take this medication every day to protect
your heart
- plavix - This medication must be taken every day for a year to
help keep your new stent open. Do not stop this medication
unless directed to do so by a cardiologist.
- atorvastatin - This is a medication to help protect the heart
and keep your cholesterol low.
- Toprol XL - This is another medication to help protect the
heart.
- Lisinopril - This is another medication to help protect the
heart and help with the healing process.
.
Please seek immediate medical attention if you develop chest
pain, shortness of breath, arm pain, nausea, vomiting,
light-headedness, dizziness, passing out, sweating, back pain,
fevers, shaking chills, bleeding or swelling in the right groin,
or night sweats.
,
You were not given a prescription for nitroglycerin because the
type of heart attack you had makes you prone to low blood
pressure. Please discuss with Dr. [**Last Name (STitle) 11493**] if you should have
nitroglycerin at home.
Followup Instructions:
Please follow-up with your new cardiologist Drs. [**Last Name (STitle) 11493**] on [**Name5 (PTitle) 2974**]
[**3-1**] at 2:00pm. His phone number is: ([**Telephone/Fax (1) 76272**] and his
address is: [**Location (un) 20588**]
Suite #2, [**Location (un) **], [**Numeric Identifier 80935**]
.
Please also follow-up with your primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20585**] on [**3-12**] at 11:45am If you need to
reschedule, please call his office at [**Telephone/Fax (1) 20587**].
Completed by:[**2109-2-28**]
ICD9 Codes: 4271, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4569
} | Medical Text: Admission Date: [**2188-10-3**] Discharge Date: [**2188-10-10**]
Date of Birth: [**2120-10-6**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Tramadol Hcl
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Massive hemoptysis
Brain masses
Major Surgical or Invasive Procedure:
Rigid bronchoscopy, flex bronchoscopy, tumor destruction,
brushings
History of Present Illness:
67yo male h/o afib, Etoh abuse, transferred from [**Hospital3 **]
[**10-3**] after presenting with syncope. On w/u found to have L
sided brain lesion and chest CT showing carinal and RUL masses.
Bronch with biopsy done with increasing hemoptysis so
transferred to [**Hospital1 18**]. At [**Hospital1 **] underwent rigid bronch revealing
RUL likely lung CA with 100% occlusion. Decision made to start
XRT therapy for chest.
Past Medical History:
lung mass with brain mass
hemoptysis
chronic afib
GERD
?seizure disorder
Etoh abuse
umbilical hernia
HTN
psoriasis
chronic venous stasis
neuropathy
cholelithiasis
Social History:
100+ pack year history
Previous etoh abuse
no IVDU
Lives with wife.
Family History:
NC
Physical Exam:
T97.8 P78 BP130/64 R18 sat 95% RA
Gen: NAD
HEENT: EOMI, PERRL, clear conj
ENT: MMM, poor dentition
CV: Irregularly irregular, no mrg
Chest: decreased BS RUL and bilat LL, no wheeze
Abd: NT, soft, +bs; +umbilical hernia
Ext: no edema
Neuro: [**6-13**] except [**3-16**] R wrist extensors/flexors and 4/5 L
triceps; CNs [**3-23**] intact except slight central VII on R; alert
and oriented x3
Pertinent Results:
[**2188-10-3**] 08:30PM FIBRINOGE-390
[**2188-10-3**] 08:30PM PT-11.9 PTT-27.8 INR(PT)-1.0
[**2188-10-3**] 08:30PM PLT COUNT-200
[**2188-10-3**] 08:30PM WBC-5.4 RBC-2.66* HGB-8.5* HCT-23.8* MCV-90
MCH-31.9 MCHC-35.7* RDW-16.3*
[**2188-10-3**] 08:30PM ALBUMIN-3.5 CALCIUM-9.3 PHOSPHATE-3.8
MAGNESIUM-1.8
[**2188-10-3**] 08:30PM LD(LDH)-130 ALK PHOS-106 TOT BILI-0.6
[**2188-10-3**] 08:30PM GLUCOSE-135* UREA N-10 CREAT-0.8 SODIUM-131*
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-13
CT chest/abd/pelvis IMPRESSION:
1. Two right lung masses; one located posteriorly in the right
upper lobe within the parenchyma, the other located in the right
hilum. It is unclear if the mass located in the parenchyma
represents primary tumor in the hilar mass, a nodal met. Other
nodes are located in the right hilum and within the mediastinum.
The appearance of these lesions are worrisome for lung
carcinoma.
2. Small pleural-based lesions within left lung also suspicious
for malignancy.
3. Pockets of mediastinal air tracking into the soft tissues of
the neck consistent with patient's recent history of
bronchoscopy.
4. Low attenuation lesion of right lobe of thyroid indeterminate
for metastatic lesion.
5. Likely a metastatic lesion of left iliac [**Doctor First Name 362**].
MRI brain: IMPRESSION:
Features most likely due to metastases, bilateral mid frontal,
right posterior parietal, and dural-based metastasis in the
anterior part of the tentorium cerebelli.
FNA, Lung, right upper lobe mass at right mainstem bronchus:
POSITIVE FOR MALIGNANT CELLS consistent with non-small cell
carcinoma.
Brief Hospital Course:
67yo male admitted after episode of hemoptysis after bronch at
[**Hospital 69597**] hospital. Began treatments for lung CA with XRT.
1) Hemoptysis: After bronch at outside hospital, hematocrit
remained stable after transfer and bronch here. No further
episodes of significant bleeding.
2) Lung CA: Pt had imaging done that showed metastatic disease,
including to brain. Biopsy revealed non small cell lung CA.
Patient started on XRT to chest here. Plan to get further
evaluation by pulmonary oncology with treatment plans for after
XRT to be made. Will return to get final of 10 total XRT
treatments next week.
3) Brain Mets: Pt appropriate while here with neuro deficits as
outlined in physical exam. Patient had mapping done for planned
brain XRT. Patient given dexamethasone 4mg q6 hours while in
hospital. Spoke with radiation oncology and decreased to
dexamethasone 4mg q8 hours on discharge. Can continue to taper
up or down as outpatient.
4) Atrial fibrillation: Remained in irregular rhythm while here.
Stopped anticoagulation after bleed. Continue digoxin. Also
atenolol decreased to 50mg qday. No events while in patient.
5) Social: Met with social work while in patient. Patient
remains up beat, wants to fight. Helped to arrange for possible
transportation to [**Hospital1 18**] in future. Wants to continue to receive
care here.
Medications on Admission:
On transfer:
cymbalta 30mg [**Hospital1 **]
decadron 4mg IV q6hours
digoxin 0.125mg qday
folate
MVI
protonix 40mg qday
tenormin 100mg qday
ventolin nebs
thiamine
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Non small cell lung cancer with metastatic disease to the brain
Hemoptysis from lung cancer
Discharge Condition:
Good
Discharge Instructions:
Continue to take all of your medications. Please call your
doctor if you become more confused, develop significant
headaches, develop fevers, chills.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2188-10-23**] 3:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2188-10-23**] 3:00
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4570
} | Medical Text: Admission Date: [**2121-12-26**] Discharge Date: [**2122-1-2**]
Date of Birth: [**2065-9-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Ambien
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation/Extubation
Diagnostic paracentesis
History of Present Illness:
56 y/o M with HCV cirrhosis with portal hypertension,portal
hypertensive gastropathy, ascites with recurrent paracenteses (
last [**12-10**]) and encephalopathy transferred from an OSH initial
presenting with altered mental status. According to the OSH
notes the patient's mental status has been gradual declining [**5-12**]
days preadmission. His wife was giving increasing doses of
lactulose last night and patient was having bowel movements,
though was sleepy. He was found to be obtunded on the day of
admission and EMS was called, at arrival to the OSH he was
intubated for airway protection and sedated with Vecuronium. The
patient was given lactulose and zosyn . He recieved a CT of the
head which was negative. Patient thought to have UTI leading to
hepatic encephalopathy at the OSH. Ammonia level was up to 230
at OSH. On transfer to [**Hospital1 **] he became agitated was given 2mg Push
of IV Midazolam.
.
Of note according to the patient's wife he has been taking "more
and more" oxycodone recently, last time being [**Hospital1 766**], (his wife
took away his oxycodone at that time) because of increasing back
pain. He took approx. 30 pills in [**3-12**] days according to his
wife. [**Name (NI) 766**] night he was disoriented and confused. He also was
constipated for approx. 3 days until teus morning when his wife
start making sure he was taking his lactulose and his BM
stabilized at 3-4/day. During the last three days pre-admission
he has been oriented and interactive though sleepy. His wife
found him this morning obtunded and unresponsive. She denies he
has had any fevers or cough in the last few days. Of note last
week the patient felt nauseous for 2 days and vomtited a unknown
number of times with worsening back pain. The nausea and back
pain improved with oxycodone.
.
In the ED, initial vs were: Temp:98.2 HR:130 BP:156/110 Resp:16
O(2)Sat:100 intubated RR 24, O2Sat 100% on AC 500x16 PEEP 5
.
Patient received a diagnostic paracentesis to assess for SBP
which was negative. He also recieved 30g Lactulose X 1.
.
On the floor, Vitals: T:98.8 BP:149/71 P:105 R:23 18 O2: 100% ,
the patient was intubated and a ABG was obtained. The patient
was switched to pressure support from assist control.
.
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,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Hepatitis C genotype 1, on liver transplant list,
non-responder to pegylated interferon and ribavirin
- Pulmonary embolism (diagnosed [**12-16**]), on warfarin until [**5-/2121**]
- Hypertension
- Depression
- Anxiety
- Migraines
- Cellulitis
- Obesity
- Left ankle fracture
- Colonic polyps
- L2+L3 compression fractures, s/p kyphoplasty
Social History:
- Employment: Case manager at the VA, working with dual
diagnosis and substance abuse counseling
- Spent years in and out of jail for selling drugs
- Tobacco: Smoked 1ppd age 11 to 25
- EtOH: Former heavy use. Last drink was [**11/2110**]
- Illicits: Marijuana, PCP, [**Name10 (NameIs) 57131**], LSD, and heroin in the
past. Sober since [**2110**].
- Married to wife [**Name (NI) **] (RN)
Family History:
No family members have experienced fevers in the past few weeks,
although children have had several tick bites. Father deceased
(48 [**Name2 (NI) 1686**]) from emphysema and mother deceased from 'old age.' No
family history of malignancy.
Alcoholism in several family members.
Physical Exam:
On admission:
VS: T=100.9, BP=128/66, HR=95, RR=18, O2 sat=97% RA
GENERAL: well-appearing middle aged male in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Liver edge palpable with slight ttp.
EXTREMITIES: No c/c/e.
SKIN: No rash appreciated near bite sites (right clavicle and
midline abdomen).
Pertinent Results:
On admission:
[**2121-12-26**] 08:57AM BLOOD WBC-8.4 RBC-4.35* Hgb-11.2* Hct-33.4*
MCV-77* MCH-25.7* MCHC-33.5 RDW-18.6* Plt Ct-66*
[**2121-12-26**] 08:57AM BLOOD Neuts-84.7* Lymphs-8.7* Monos-4.4 Eos-1.7
Baso-0.5
[**2122-1-2**] 05:00AM BLOOD WBC-1.8* RBC-3.17* Hgb-8.6* Hct-24.9*
MCV-79* MCH-27.0 MCHC-34.3 RDW-18.4* Plt Ct-26*
[**2122-1-1**] 07:12AM BLOOD Neuts-61 Bands-0 Lymphs-27 Monos-7 Eos-5*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2122-1-1**] 07:12AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-3+
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-3+ Tear
Dr[**Last Name (STitle) 833**].
[**2121-12-26**] 08:57AM BLOOD PT-15.1* PTT-28.8 INR(PT)-1.3*
.
[**2121-12-26**] 08:57AM BLOOD Glucose-151* UreaN-20 Creat-1.3* Na-136
K-5.2* Cl-103 HCO3-25 AnGap-13
[**2121-12-30**] 03:10PM BLOOD Glucose-84 UreaN-20 Creat-1.7* Na-134
K-4.3 Cl-100 HCO3-29 AnGap-9
[**2121-12-31**] 05:10AM BLOOD Glucose-101* UreaN-20 Creat-1.5* Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2122-1-1**] 07:12AM BLOOD Glucose-85 UreaN-20 Creat-1.4* Na-138
K-3.8 Cl-105 HCO3-25 AnGap-12
[**2122-1-2**] 05:00AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-132*
K-3.9 Cl-104 HCO3-24 AnGap-8
.
[**2121-12-26**] 08:57AM BLOOD ALT-50* AST-60* AlkPhos-182* TotBili-1.9*
[**2121-12-26**] 08:57AM BLOOD Lipase-38
[**2121-12-26**] 08:57AM BLOOD Albumin-3.8 Calcium-8.8 Phos-4.2 Mg-2.3
[**2121-12-28**] 03:10AM BLOOD calTIBC-386 Hapto-51 Ferritn-27* TRF-297
[**2121-12-26**] 10:50AM BLOOD Ammonia-131*
.
[**2121-12-26**] 08:57AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2121-12-26**] 05:38PM BLOOD Type-ART Temp-37.1 Tidal V-700 PEEP-5
FiO2-50 pO2-107* pCO2-35 pH-7.44 calTCO2-25 Base XS-0
Intubat-INTUBATED
[**2121-12-26**] 09:40AM BLOOD Lactate-2.4*
[**2121-12-26**] 05:38PM BLOOD freeCa-1.11*
.
[**2121-12-26**] 09:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2121-12-26**] 09:50AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2121-12-26**] 09:50AM URINE RBC-[**12-27**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2121-12-26**] 09:50AM URINE Mucous-RARE OvalFat-MOD
[**2121-12-26**] 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
[**Month/Day/Year 57131**]-NEG amphetm-NEG mthdone-NEG
[**2121-12-26**] 09:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2121-12-26**] 09:50AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2121-12-26**] 09:50AM URINE RBC-[**12-27**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2121-12-26**] 09:50AM URINE Mucous-RARE OvalFat-MOD
[**2121-12-31**] 07:42PM URINE Hours-RANDOM UreaN-539 Creat-137 Na-36
K-49 Cl-11
[**2121-12-31**] 07:42PM URINE Osmolal-410
[**2121-12-26**] 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
[**Month/Day/Year 57131**]-NEG amphetm-NEG mthdone-NEG.
.
[**2121-12-26**] 09:47AM ASCITES WBC-248* RBC-523* Polys-13* Lymphs-18*
Monos-43* Mesothe-2* Macroph-22* Other-2*
.
[**2122-1-1**] 07:12AM BLOOD PT-16.9* INR(PT)-1.5*
[**2122-1-2**] 11:00AM BLOOD PT-16.7* INR(PT)-1.5*
.
IMAGING
CXR [**2121-12-26**]:
IMPRESSION: Endotracheal and nasogastric tubes in appropriate
position as
detailed above. Very limited evaluation of the lungs given the
profoundly low lung volumes. There is, however, extensive patchy
opacity at the left lung and aspiration versus pneumonia is
highly likely.
.
CT head w/o contrast [**2121-12-26**]:
IMPRESSION: No acute intracranial process. Nasal secretions
likely related
to intubated status.
.
RUQ ultrasound [**2121-12-26**]:
IMPRESSION:
1. Cirrhotic liver. Previously seen liver cyst and enhancing
lesions are not identified on the current study.
2. Patent main portal vein.
3. Stable splenomegaly.
4. Stable thickening of the gallbladder wall, likely secondary
to hyperproteinemic state.
CULTURE DATA
Time Taken Not Noted Log-In Date/Time: [**2121-12-26**] 9:40 am
BLOOD CULTURE TRAUMA/ARREST SET#1.
**FINAL REPORT [**2122-1-1**]**
Blood Culture, Routine (Final [**2122-1-1**]): NO GROWTH.
[**2121-12-26**] 9:47 am PERITONEAL FLUID
TRAUMA/ARREST ,PERITONEAL FLUID..
**FINAL REPORT [**2122-1-1**]**
GRAM STAIN (Final [**2121-12-26**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2121-12-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2122-1-1**]): NO GROWTH.
[**2121-12-26**] 9:50 am URINE Site: CATHETER
TRAUMA/ARREST,CATHETER\.
**FINAL REPORT [**2121-12-27**]**
URINE CULTURE (Final [**2121-12-27**]): NO GROWTH.
[**2121-12-26**] 8:55 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2121-12-28**]**
GRAM STAIN (Final [**2121-12-26**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2121-12-28**]):
SPARSE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
56 y/o M with HCV cirrhosis with portal hypertension, portal
hypertensive gastropathy, ascites with recurrent paracenteses
(last [**12-10**]) and encephalopathy transferred from an OSH with
altered mental status and intubated for airway protection.
.
#Altered Mental status- Given the patient's history hepatic
encephalopathy is the most probable cause. The differential of
this acute encephalopathy includes infection, drug overdose, or
GI bleeding.The patient currently has no signs of GI bleeding.
The patient has been afebrile and currently has no leukocytosis.
On OSH records the patient had a UA indicating a UTI, however on
the UA we obtained the results did not indicate a active UTI.
The patient also has been taking increasing amounts oxycodone in
the last week which is a possible etiology causing his acute
hepatic encephalopathy. He also has evidence of left lung field
opacities which are consistent with pneumonia or aspiration.
Therefore it could have been the patient developed a pneumonia
in the last few days as an outpatient or aspirated recently
given his altered mental status and intubation. He was started
empirically on levofloxacin for PNA this was discontinued after
6 days for pancytopenia. Sputum cx negative. CT head was
negative for acute bleed or stroke and no history consistent
with seizure like activity. All sedative drugs were stopped. He
was stabilized in the MICU and extubated w/o complication, and
transferred to the general liver wards.
He noted to have mild flap on transfer. Patient received a
diagnostic paracentesis to assess for SBP which was negative.
Lactulose and rifaximin restarted. Urine and blood cx negative.
MS continued to improve w lactulose and he reached MS baseline
on the day after transfer out of the MICU with noted resolution
of asterixis at that time as well.
.
#Respiratory Status - The patient was on assist control on
transfer and recently transitioned to pressure support with a
stable ABG after. Will ensure the patient is ventilating
appropiately by following his minute ventilation . Will attempt
to wean off the propofol to assess his mental status more
appropiately. He was extubated successfully on [**12-27**]. Pt was
comfortable on room air at time of transfer to general floor.
.
#Pneumonia- Has X ray evidence with left lung field opacities,
though no leukocytosis or fevers. Could be community acquired or
aspiration as etiology. He was covered w levofloxacin for
empiric pna on [**12-26**] and this antibiotic was discontinued after
6 days for negative sputum, blood, and urine cultures. He also
was asymptomatic. Pt developed pancytopenia 4 days after
initiation of levofloxacin.
.
#Thrombocytopenia- According to our records the patient's
platelet count is typically between 50-100. Platelet count noted
to downtrend 2 days after initiating levofloxacin. He did not
require transfusion of platelets. Would expect resolution of
suppression w abstinence from antibiotics. Plan to monitor on
outpt setting w labs after discharge. Pt was informed to seek
medical attention if febrile, or active bleeding.
.
#Anemia- According to the patient's history he has a microcytic
anemia, and currently is consistent with baseline hematocrit. On
admission pt had no active signs of gastrointestinal bleeding.
He was guaiac negative on general floors. Pancytopenia developed
on [**12-28**] and pt noted to have downtrending Hct [**3-11**] suppression
from levofloxacin. He was transfused 2units of packed RBCs
during his stay w/o any sign of active bleeding. Hct stable at
time of discharge.
.
#Cirrhosis- On admission, this pt was on the transplant list
however given his recent drug use/oxycodone abuse, it was
decided to inactive him at the Tuesday transplant meeting on
[**2121-12-30**]. Pt and family was notified. Pt scheduled for outpt
therapeutic paracentesis in next 2 weeks after discharge. RUQ
u/s shows patency and moderate ascites. No para indicated given
no interval increase in abd girth or ascites and poor amt of
fluid available on [**12-10**] outpt attempt at para.
.
# [**Last Name (un) **]: Acute increase from baseline 1.2 to 1.7 on [**12-30**]
attributed to diuretics, poor po intake prior to admission.
Diuretics were held and he was administered volume challenge
with albumin dosed 1gm/kg x 2 days and 75g x 1 day. Creatinine
downtrended close to baseline at time of discharge. Plan to
follow up at clinic appt. Diuretics were held and plan to assess
and restart at appt f/u w Dr. [**Last Name (STitle) 497**] in 2 weeks.
.
#Substance abuse: Pt admits to abuse of oxycodone prior to
admission. Social work consulted on admission and provided
resources for follow up and referral to transplant psychiatry.
Opioids, narcotics, and benzodiazepines were avoided during his
stay. He was discharged on a temporary amount of seroquel per
inpt psychiatry recommendation prn insomnia. He was advised to
follow up with outpt PCP for assessment and discussion about
further sleep aides. Was advised to avoid any potentially
addictive medications. Consider antidepressant as outpt.
Medications on Admission:
Ergocalciferol (vitamin D2) 50,000 unit Capsule
one Capsule(s) by mouth weekly for 12 weeks [**2121-10-21**]
Furosemide 40 mg Tablet 1.5 Tablet(s) by mouth once a day.
Lactulose 10 gram/15 mL Solution 60 cc(s) by mouth three times a
day.
Lidocaine 5 % (700 mg/patch) Adhesive Patch, Medicated
2 Adhesive(s) DAILY (Daily) Apply one to lower back, one to
mid-back. Leave on 12 hours, off 12 hours.
Midodrine 5 mg Tablet 1 [**2-8**] Tablet(s) by mouth 3 times a day
Oxycodone 5 mg Capsule 1 Capsule(s) by mouth four times per day.
Potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
1 Tab(s) by mouth once a day
Rifaximin [Xifaxan] 550 mg Tablet 1 Tablet(s) by mouth twice a
day [**2121-10-15**]
Spironolactone 50 mg Tablet 3 Tablet(s) by mouth once a day
Testosterone [AndroGel] 1.25 gram per Actuation (1 %) Gel in
* OTCs *
Calcium carbonate-vitamin D3
500 mg (1,250 mg)-400 unit Tablet
1 Tablet(s) by mouth twice a day
Magnesium oxide 400 mg Tablet 2 Tablet(s) by mouth twice a day
Discharge Medications:
1. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
2. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO three times
a day.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Opioid overdose
Hepatic encephalopathy
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 altered mental status that
appear related to the oxycodone you ingested. You were also
confused which is likely related to constipation secondary to
the painkillers. You required admission to the intensive care
unit for monitoring and were given antibiotics for a presumed
pneumonia found on chest xray.
You will need to continue these oral medications for a full 7
day course (day 1 on [**12-26**]).
.
For your recent substance abuse, social work was consulted and
they have provided you with resources for recovery and
rehabilitation. It is essential that you abstain from drug and
alcohol abuse given your significant liver disease.
.
The following changes were made to your medications:
Restarted midodrine for your kidneys and blood pressure.
Stopped oxycodone, sedatives
Stopped lasix and spironolactone (water pill)
Started seroquel to assist in sleep. You received a temporary
supply, any sleep aides, painkillers, or other potentially
addictive medications will need to be managed by one physician.
[**Name10 (NameIs) 357**] address this issue with your PCP.
.
It is important that you avoid any addictive medications
including sedatives, opioids/high potency painkillers, or
benzodiazepines.
.
Please follow up with your physicians as stated below.
*You need to make an appt with your pcp for sometime in the next
week.*
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2122-1-7**] at 1:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2122-6-17**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
ICD9 Codes: 486, 5849, 5715, 2875, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4571
} | Medical Text: Admission Date: [**2135-8-22**] [**Month/Day/Year **] Date: [**2135-8-30**]
Date of Birth: [**2064-2-24**] Sex: F
Service: MEDICINE
Allergies:
Streptomycin / Versed / Fentanyl
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 18536**] is a 71F with hypothyroidism, DM, afib, pulm HTN,
and h/o urinary retention who was brought to the ER for
evaluation of confusion.
.
On the afternoon of presentation, she was out with her relatives
when she complained of chills and became confused. EMS was
called and they report her glucose was in the 20s. She was given
an amp of D50, with glucose in the 200s after. She was brought
in the ED where her initial vs were T 95 HR 79 BP 87/47 SaO2
97%, fingerstick 264. She was given intravenous fluids and her
blood pressure improved to 89-95/ 50-70. She received a total of
5L of IVF. Her INR was 4.0 and a central line was not placed. A
bedside ultrasound showed mild pericardial effusion. CTA torsoe
was without evidence of dissection. ECG showed Afib with rate in
the 70s. No evidence of block. She was given vancomycin and
piperacillin/tazobactam. Head CT was negative.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Atrial fibrillation.
2. Hypertension.
3. Dyslipidemia.
4. Obstructive sleep apnea with secondary pulmonary HTN (uses
CPAP but does not know settings)
5. Chronic diastolic heart failure.
6. Diabetes mellitus type 2; [**2135-1-31**] HbA1c 7.9
7. Chronic kidney disease (baseline Cr ~1.2)
8. S/p lap appy ([**9-12**])
9. Diabetic neuropathy
Social History:
She lives with her husband. She does not use tobacco and has no
history of alcohol abuse. She already has VNA and home-health
aid weekly. She has a supportive family in the [**Location (un) 86**] area and
at baseline walks with a cane
Family History:
There is no family history of premature coronary artery disease
Physical Exam:
H&P Per Admitting Resident
General: Alert, oriented x self
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NE: CN2-12 intact, PERRL, EOMI
Pertinent Results:
Admission Labs:
WBC-5.1 RBC-3.75* Hgb-10.4* Hct-33.6* MCV-90 MCH-27.7 MCHC-31.0
RDW-16.3* Plt Ct-119*
Neuts-67.2 Lymphs-24.9 Monos-4.9 Eos-2.5 Baso-0.6
PT-38.7* PTT-33.7 INR(PT)-4.0*
Glucose-199* UreaN-39* Creat-1.6* Na-138 K-3.8 Cl-99 HCO3-28
AnGap-15
ALT-24 AST-36 CK(CPK)-76 AlkPhos-46 TotBili-0.3
Lipase-113*
Calcium-9.0 Phos-3.5 Mg-2.5
cTropnT-<0.01
TSH-8.8*
Lactate-1.3
.
[**Location (un) **] Labs:
WBC-4.5 RBC-2.56* Hgb-7.2* Hct-23.3* MCV-91 MCH-28.3 MCHC-31.1
RDW-15.1 Plt Ct-141*
PT-23.0* PTT-29.5 INR(PT)-2.2*
Glucose-93 UreaN-41* Creat-1.3* Na-141 K-4.2 Cl-98 HCO3-37*
AnGap-10
Calcium-8.4 Phos-3.7 Mg-2.7*
Misc Labs:
VitB12-292
calTIBC-300 Ferritn-126 TRF-231
Hapto-135
%HbA1c-7.7*
TSH-8.8*
T4-5.7
Cortsol-9.2
PEP-NO SPECIFIC ABNORMALITIES
Cardiac Biomarkers:
[**2135-8-21**] 09:50PM BLOOD CK(CPK)-76 CK-MB-NotDone cTropnT-<0.01
[**2135-8-22**] 03:38AM BLOOD CK(CPK)-71 CK-MB-NotDone cTropnT-<0.01
[**2135-8-22**] 11:19AM BLOOD CK(CPK)-
.
IMAGING:
.
CXR ([**8-21**]) - IMPRESSION: Low lung volumes with basilar likely
atelectasis.
CXR ([**8-24**]) - IMPRESSION: AP chest compared to [**3-30**] and
[**8-21**], read in conjunction with chest CTA [**8-21**]: Mild
cardiomegaly and mediastinal vascular engorgement have both
increased since [**8-21**], suggesting volume overload. No clear
pulmonary edema. Pleural effusion if any is small, on the
right. No pneumothorax.
.
CXR ([**8-26**]) - IMPRESSION: Bilateral lower lobe atelectasis can be
explained by low lung volumes. New consolidation in the left mid
lung.
.
CT Torso - IMPRESSIONS:
1. No findings to account for the patient's symptoms.
Specifically, no aortic dissection or aneurysm. No pericardial
effusion. No definite large pulmonary embolus.
2. No definite acute intra-abdominal pathology is seen, although
assessment
is slightly limited due to tailoring of the study towards
assessment of the aorta. Perihepatic ascites is decreased.
Cholelithiasis. Mild splenomegaly. Diastasis of the rectus
muscles, with small fat-containing paraumbilical hernia.
Brief Hospital Course:
# AMS, Hypothermia, Hypotension - Although initially concerning
for SIRS, the patient's altered mental status was likely
secondary to her hypoglycemia. She was given an amp of D50 in
the field when she was hypoglycemic and her glucose responded
appropriately. She was started on vancomycin and zosyn
empirically at admission, but these were d/c'ed when her blood
and cultures remained negative. She also ruled out for ACS with
three sets of negative cardiac enzymes. Her cortisol level was
normal. She was found to have an elevated TSH with a normal FT4.
On the day of [**Month/Year (2) **] from the MICU, the patient developed a
episode of oxygen desaturation and was started on levofloxacin
(see below). By the time she was transferred to the floor, the
patient was alert and oriented to person, place, and time, and
her hypothermia and hypotension had resolved. She remained that
way for the remainder of her hospital course.
.
# Pneumonia - The patient was intially started on broad coverage
with vancomycin and zosyn at admission. However, because
cultures were negative and the patient was stable, these
antibiotics were stopped on [**8-23**]. However, on [**8-24**], the patient
developed a episode of oxygen desaturation. CXR was done and was
suspicious for a new opacification in the right lower lung. She
was started on levofloxacin to complete a 7 day course (3 doses
of levofloxacin q48 hours). She had some low-grade fevers in
her initial days on the floor. However, her fevers improved and
she was afebrile at [**Month/Year (2) **]. Of note, during her hospital
stay, the patient continued to require 2 L of O2. There were
some discrepancies as to whether she actually uses oxygen at
home. She denied any dyspnea over her baseline, however. It is
likely that some of this oxygen requirement was secondary to her
frequent refusal to use neb treatments, her insistence to lay
flat in bed, and her refusal to use the hospital CPAP machine.
She was discharged on home O2.
.
# Hypoglycemia - Seems that patient's hypoglycemia on admission
was likely secondary to taking exogenous insulin, glipizide, and
possibly poor PO intake. On admit, her glipizide was
discontinued and she was placed on sliding scale insulin. Once
she was on the floor, [**Last Name (un) **] was consulted and placed the
patient on a regimen of 75/25 [**Hospital1 **] with an insulin sliding scale
to cover for hyperglycemia. Her [**Hospital1 **] dosing was adjusted during
her hospitalization and she was discharged on a regimen of 70/30
[**Hospital1 **] with an insuling sliding scale. She was also scheduled for
follow-up with the [**Hospital **] clinic.
.
# Atrial Fibrillation - On admission to the MICU, the patient's
nodal blocking agents were intially held. She did develop some
episodes of RVR, which responded to IV metoprolol and diltiazem.
Her PO metoprolol and diltiazem were restarted prior to
transfer to the floor. Of note, her metoprolol dose was
increased to 37.5 mg [**Hospital1 **]. On the floor, she did have a few
episodes of RVR, but they were all in the setting of her
dilatizem having been held secondary to hypotension. She was
discharged on her diltiazem and the new dose of metoprolol. Of
note, on admission, the patient's INR was supratherapeutic at 4.
Her warfarin was held and was later restarted. Initially, her
warfarin was restarted at a lower dose because she was on
levofloxacin. However, the patient was discharged on her
regular dose of 5 mg of warfarin
.
# Hypertension - While on the floor, the patient was mantained
on diltiazem, lasix, lisinopril, and metoprolol. Her blood
pressures remained stable and she was discharged on this
regimen.
.
# OSA - The patient had a history of obstructive sleep apnea
with home CPAP. She refused to use the hospital CPAP machine.
Attempts to have her home CPAP machine brought in were
unsuccessful (her family brought in the mask only, which did not
work with the hospital machine).
.
# Dyslipidemia - While in-house, the patient was continued on
her home dose of atorvastatin. Her TriCor was held on admission
but was restarted at [**Hospital1 **].
.
# Chronic Kidney Disease - Through her hospitalization, the
patient's creatinine ranged between 1.3 and 1.7. This appeard
to be consistent with the range that the patient had recently
been running.
.
# Anemia - The patient's Hct ranged between 23.3 and 33.6. The
patient's baseline appeared to be around 27 to 30. Stool were
guaiac-negative.
.
# Diastolic Heart Failure, Diabetic Neuropathy, Osteoarthritis -
There were no acute issues during this hospitalization.
Medications on Admission:
Diltiazem SR 240 mg p.o. b.i.d.
lisinopril 10 mg half q.d.
glipizide 5 mg 2 in the morning and one at night
Synthroid 88mcg p.o. q.d.
Lasix 40 mg b.i.d.
folic acid 1 mg q.d.
amitriptyline 20 mg at night
Lipitor 10 mg q.d.
TriCor 145 mg p.o. q.d.
insulin 70/30 38 in the morning and 22 at night
Coumadin
Colace 100 mg p.o. b.i.d.
Prilosec 20 mg p.o. q.d.
senna p.r.n.
Estrace vaginal cream
oxygen 2 L /min via NC prn.
metoprolol 25 mg in a.m. and 12.5 in p.m.
[**Hospital1 **] Medications:
1. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO twice a day.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for constipation.
14. Estrace Vaginal
15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous As
Directed: Please measure your blood sugars four times a day and
use the sliding scale provided at [**Hospital1 **].
Disp:*1 month's supply* Refills:*2*
16. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Home Oxygen
Oxygen at 2 liters via nasal cannula continuously pulse-dosed to
keep oxygen saturation above 90%.
Diagnosis: pulmonary hypertension
18. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: As Directed Subcutaneous twice a day: Please administer 38
units with breakfast and 22 units with dinner.
Disp:*1 month's supply* Refills:*2*
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
[**Hospital1 **] Diagnosis:
Primary:
Pneumonia
Acute hypoglycemia
Altered mental status
Atrial fibrillation with rapid ventricular response
Secondary:
Diabetes mellitus
Hypertension
Obstructive Sleep Apnea
Pulmonary hypertension
[**Hospital1 **] Condition:
Afebrile, Hemodynamically Stable.
[**Hospital1 **] Instructions:
You were admitted because of low blood sugar and low body
temperature. Your symptoms were likely secondary to a reaction
to insulin. We monitored your body temperature and blood
sugars. You also had some low oxygen levels, fevers, and
changes on your x-ray that were concerning for pneumonia.
Therefore, you were started on an antibiotic to treat this.
Changes to your medications:
START Levofloxacin 750 mg every 48 hours for three doses (last
dose on [**8-28**])
STOP Glipizide
CHANGE Metoprolol to 37.5 mg twice a day
CHANGE Levothyroxine to 100 mcg daily
Also, CHANGE your insulin regimen to the following:
Humalin 70/30: 38 units at breakfast and 22 units at dinner
Humalog Sliding Scale (follow the sliding scale provided by your
nurse [**First Name (Titles) **] [**Last Name (Titles) **])
Please return to the emergency department for any fevers greater
than 101.5, shortness of breath, chest pain, confusion, or any
other concerning symptoms.
It was a pleasure taking part in your medical care.
Followup Instructions:
Scheduled Appointments:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**2135-9-1**] at 11:30 am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP ([**Hospital **] Clinic) [**2135-9-2**] at 8:30 am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ([**Telephone/Fax (1) 62**]) [**2135-11-23**] at 2:20 pm
ICD9 Codes: 486, 4280, 3572, 4168, 2449, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4572
} | Medical Text: Admission Date: [**2124-1-17**] Discharge Date: [**2124-1-23**]
Date of Birth: [**2071-2-5**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
vomiting, diarrhea, and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 52 year-old male with a history of alcoholism who
presents with confusion, also nausea, vomiting, and epigastric
pain. He began vomiting last night and says he has vomited
almost continously, small volumes; told the ED the vomitus was
clear liquid, told me it was blood. Also frequent, watery
diarrhea. Says his "stomach hurts," and gestures towards his
epigastrium, but will not futher describe the abd pain.
.
In the ED, he confessed his last drink was about 24 hours ago
(he usually drinks 1-2 bottles of whiskey a day). He was
oriented to person, place, and time, but alternately confused,
and for suspected EtOH withdrawal, he received 30mg of valium
(IV). VS 97.8, 110, 130/80, 20, 99% RA.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
Alcohol abuse, including admission in [**9-/2123**] & [**10/2123**] for
withdrawal, left AMA both times; says he has had DTs, although
this is not documented in OMR
Seizures, not clear if related to alcohol withdrawal or not
H/o MI 7 years ago
Hypertension
Hepatitis C Virus
History of a positive PPD in [**5-18**]
Asymptomatic bradycardia
Depression
Anxiety
COPD
GERD
Hiatal Hernia
Social History:
Patient has a 40 pack year history of smoking. Drinks mutiple
bottles of alcohol daily, whiskey, sometimes vodka. Denies any
drug use or history of IVDA. Says he now lives alone in a house
in [**Location (un) **].
Family History:
Noncontributory
Physical Exam:
Vitals: T:98.6 BP:144/89 HR:100 RR:14 O2Sat:97% on 2L, drops
transiently to 88 on RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear. + rhinophyma
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, but not time. CN II ??????
XII grossly intact. Moves all 4 extremities. Strength 5/5 in
upper and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction. No
asterixis, mild tremor.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2124-1-17**] 10:15AM PLT SMR-NORMAL PLT COUNT-438
[**2124-1-17**] 10:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2124-1-17**] 10:15AM NEUTS-75* BANDS-3 LYMPHS-12* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-1-17**] 10:15AM WBC-11.4*# RBC-4.59* HGB-14.6 HCT-39.3*
MCV-86 MCH-31.9 MCHC-37.2* RDW-16.0*
[**2124-1-17**] 10:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-1-17**] 10:15AM OSMOLAL-299
[**2124-1-17**] 10:15AM ALBUMIN-4.1 CALCIUM-8.4 PHOSPHATE-2.7
MAGNESIUM-1.7
[**2124-1-17**] 10:15AM LIPASE-11
[**2124-1-17**] 10:15AM ALT(SGPT)-33 AST(SGOT)-31 ALK PHOS-75 TOT
BILI-0.6
[**2124-1-17**] 10:15AM GLUCOSE-135* UREA N-45* CREAT-1.7* SODIUM-137
POTASSIUM-3.3 CHLORIDE-84* TOTAL CO2-24 ANION GAP-32*
[**2124-1-17**] 02:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2124-1-17**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-1-17**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2124-1-17**] 02:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2124-1-17**] 02:30PM URINE GR HOLD-HOLD
[**2124-1-17**] 02:30PM URINE HOURS-RANDOM
[**2124-1-17**] 02:30PM URINE HOURS-RANDOM UREA N-848 CREAT-74
SODIUM-22 POTASSIUM-30 CHLORIDE-26
.
CT Abd/Pelvis:
IMPRESSION:
1. No evidence of colitis or acute intra-abdominal process.
2. Vague fat density adjacent to the sigmoid colon likely
reflects a normal branching pattern of mesocolic vessels;
considered unlikely to represent epiploic appendagitis.
3. Fatty liver.
4. Atherosclerotic calcification of the abdominal aorta.
5. Chronic appearance of right middle lobe consolidation, likely
chronic/rounded atelectasis.
Brief Hospital Course:
# EtOH withdrawal: Somnolent but interactive at the time of
admission, and not cooperative, though not tremulous. After
hydration and antibiotics overnight, patient was fully oriented,
no tremulousness or asterixis. Patient required valium
approximately every 6 hours overnight his first night of
admission. He was continued on a CIWA scale, received banana
bag in ED, and was continued on thiamine, folate IV x3 days,
multivitamin. He was subsequently discontinued off of valium,
and did not require further benzodiazepine. He refused further
social work assistance regarding sobriety.
.
# Abdominal pain: On presentation, he complained of abdominal
pain, diffuse throughout his abdomen, with nausea and vomiting.
He had an abdominal CT scan that showede no evidence of colitis
or gastroenteritis. Stool studies were negative for infectious
pathogens, although clostridium dificile was not sent. He was
given IVF and antiemetics. He was seen by the gastroenterology
service, who concluded that this was likely viral
gastroenteritis with post infectious pain syndrome, possible
exacerbated by chronic abdominal pain. He was a difficult
historian given underlying history of severe alcohol abuse. He
was treated with twice daily protonix, maalox and lidocaine. He
was discharged off of pain medications, with direction to follow
up with gastroenterology if the pain persisted. He did continue
to have pain and have decreased oral intake throughout his stay.
.
# Acute renal failure: He was admitted with a creatinine of 1.7,
which improved with hydration. This was due to dehydration.
.
# Coronary artery disease: continued aspirin
.
# Cognitive deficits: He has had neuropsychiatric testing done
as an outpatient, which showed evidence of cognitive deficits,
likely from heavy alcohol abuse. He was seen by psychiatry here
in the hospital, but there was no acute psychiatric issue
present, aside from his substance abuse. He also has a history
of violent behavior, and on the day prior to discharge, a code
purple was called after he appeared to throw his tray on the
floor and start to scream expletives. After this episode, based
on Mr. [**Known lastname 90958**] request, his care was transitioned from me,
[**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who discharged him the
following day.
.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*3*
8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
11. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH Withdrawal
Abdominal Pain, likely ETOH PUD
Gastroenteritis
ETOH abuse
Depression
Hypophosphatemia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having high fevers, vomitting blood, a
significant amount of red blood in the stool, unconsciousness.
DO NOT DRINK ALCOHOL!!! THIS WILL MAKE YOUR ABDOMINAL PAIN WORSE
NOT BETTER!!
Followup Instructions:
Patient to schedule f/u with his PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **].
[**Telephone/Fax (1) 92717**].
Patient to schedule f/u with Dr [**Last Name (STitle) 106949**] [**Name (STitle) **] or Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] of GI for outpatient EGD per patient desire.
Patient can call [**Telephone/Fax (1) 2756**] to arrange an appointment.
ICD9 Codes: 5849, 2768, 496, 4019, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4573
} | Medical Text: Admission Date: [**2138-3-17**] Discharge Date: [**2138-3-22**]
Date of Birth: [**2075-2-22**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension, fever
Major Surgical or Invasive Procedure:
Hemodialysis, placement of a dialysis catheter
History of Present Illness:
Mr. [**Known lastname 32034**] is a 63 yo M s/p cadaveric renal transplant [**3-15**]
polycystic kidney disease on tacrolimus and prednisone,
metastatic prostate cancer, and MGUS who presents with fevers
from his rehabilitation facility. Of note, he had been recently
hospitalized at [**Hospital1 18**] [**Date range (1) 111347**] for shoulder and arm pains. He
developed leukocytosis and loose stools during this
hospitalization for which he was treated with flagyl empirically
for two weeks ending on [**3-8**]. Per his rehab records, PO
vancomycin was restarted on [**3-10**]. At rehab, stool had been C
diff+ as recently as 1/30 per the records available to us.
Per his wife, he developed a fever to 101F the evening prior to
admission, without any associated chills or sweats. He also
complained of left thigh pains.
Review of systems is otherwise negative for headache, vision
changes, neck stiffness, cough, chest or abdominal pain, rash,
discharge or redness from his urostomy site. He has had loose
stools, nonwatery, without any gross bleeding in ~2 weeks.
In the ED, vitals were T 98.5 P 120 BP 86/54 RR 16 O2 96%. The
sepsis protocol was initiated and a central line was placed.
Patient initially had a CVP of 2 cm, with good response to IVF
(~2L but total amount not clear from transfer notes). He
received solumedrol and dexamethasone, as well as zosyn 4.5g,
vancomycin 1g, and flagyl 500mg. He was also started on
neosynephrine for additional blood pressure support.
Past Medical History:
Polycystic kidney disease s/p cadaveric transplant x2 [**2118**]/[**2131**]
Metastatic prostate cancer (mets to spine) on Lupron
Chronic LE edema
SCC skin
HIT
MGUS
Hx c. difficile
RUE cellulitis
UGIB [**3-15**] gastritis
Gout
Social History:
Married, admitted from [**Hospital3 **]
Family History:
noncontributory
Physical Exam:
General chronically ill appearing, no acute distress
HEENT sclera white conjunctiva pink, L eye a little swollen with
crusting
Neck supple, LIJ in place
Pulm lungs clear bilaterally
CV regular rate S1 S2 II/VI systolic murmur
Abd soft +bowel sounds well healed scar RLQ mild discomfort to
palpation RLQ, urostomy with pink stoma no exudate or erythema
Extrem 2+ pitting edema bilateral LE with faint erythema of skin
bilaterally, patient says this is a chronic issue for him. range
of motion of LE bilaterally limited by discomfort. skin bruised,
tophi present
Neuro alert and oriented x3, moving all extremities
Pertinent Results:
[**2138-3-17**] 12:15PM BLOOD WBC-7.7 RBC-2.80*# Hgb-7.4*# Hct-24.8*#
MCV-88 MCH-26.5* MCHC-30.0* RDW-16.7* Plt Ct-169
[**2138-3-21**] 04:37AM BLOOD WBC-5.1 RBC-3.26* Hgb-8.5* Hct-27.8*
MCV-85 MCH-26.1* MCHC-30.6* RDW-16.3* Plt Ct-233
[**2138-3-17**] 12:15PM BLOOD PT-16.8* PTT-40.3* INR(PT)-1.5*
[**2138-3-18**] 01:55PM BLOOD PT-13.9* PTT-32.0 INR(PT)-1.2*
[**2138-3-17**] 07:46PM BLOOD Fibrino-399
[**2138-3-17**] 12:15PM BLOOD Glucose-141* UreaN-81* Creat-3.2* Na-146*
K-3.7 Cl-122* HCO3-10* AnGap-18
[**2138-3-20**] 04:52AM BLOOD Glucose-152* UreaN-113* Creat-5.2* Na-138
K-5.2* Cl-109* HCO3-13* AnGap-21*
[**2138-3-21**] 04:37AM BLOOD Glucose-173* UreaN-87* Creat-4.4* Na-143
K-4.3 Cl-111* HCO3-19* AnGap-17
[**2138-3-17**] 01:20PM BLOOD ALT-5 AST-10 CK(CPK)-12* AlkPhos-64
TotBili-0.3
[**2138-3-17**] 07:46PM BLOOD CK(CPK)-17* Amylase-45
[**2138-3-18**] 05:42AM BLOOD CK(CPK)-11*
[**2138-3-18**] 01:56PM BLOOD CK(CPK)-10*
[**2138-3-20**] 04:38PM BLOOD proBNP-[**Numeric Identifier **]*
[**2138-3-17**] 01:20PM BLOOD CK-MB-3 cTropnT-0.47*
[**2138-3-17**] 07:46PM BLOOD CK-MB-3 cTropnT-0.42*
[**2138-3-18**] 05:42AM BLOOD CK-MB-4 cTropnT-0.35*
[**2138-3-18**] 01:56PM BLOOD CK-MB-4 cTropnT-0.33*
[**2138-3-17**] 12:15PM BLOOD Calcium-5.8* Phos-3.0 Mg-1.2*
[**2138-3-21**] 04:37AM BLOOD Calcium-8.1* Phos-5.5* Mg-1.9
[**2138-3-17**] 01:20PM BLOOD Cortsol-20.9*
[**2138-3-21**] 04:37AM BLOOD Vanco-26.2*
[**2138-3-20**] 04:52AM BLOOD FK506-5.3
[**2138-3-17**] 12:27PM BLOOD Glucose-135* Lactate-1.2 Na-137 K-3.5
Cl-124* calHCO3-10*
[**2138-3-17**] 04:40PM BLOOD Lactate-1.0
CT Abd/Pelvis/Thigh 2/4/8:
1. Interval development of bilateral pleural effusions, left
greater than right, compared to the previous study of [**9-13**]. Extensive new subcutaneous stranding and fluid. While the
majority of this could represent anasarca, there is a more focal
area of soft tissue density in the medial right thigh (not fully
evaluated given the lack of intravenous contrast), which most
likely represents hematoma, although a metastatic focus or an
area of infection cannot be entirely excluded.
3. Diverticulosis without diverticulitis.
CXR 2/4/8:
1. Left IJ terminates at the origin of the SVC.
2. Moderate congestive heart failure.
Renal Ultrasound 2/5/8:
Transplant kidney in the left lower quadrant shows normal
echogenicity and vascularity. Size of the left transplant kidney
is 10.3 cm, grossly unchanged. There is no hydronephrosis,
calculus, or perinephric fluid collection. Doppler and spectral
analysis shows normal vascularity and waveform, with resistive
indices of 0.7, 0.6 and 0.6, within the range of normal, in the
upper, mid, and lower poles.
TTE [**2138-3-18**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with akinesis of the basal inferior wall and hypokinesis of the
more distal segments. There is mild hypokinesis of the remaining
segments (LVEF = 40%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis (area 1.0cm2). Mild to moderate
([**2-12**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. There
is very mild mitral regurgitation. The estimated pulmonary
artery systolic pressure is high normal. There is a very small
anterior pericardial effusion.
CXR [**2138-3-20**]:
Worsening of pulmonary edema and bilateral pleural effusions
with overall distention in mediastinal vasculature consistent
with volume overload.
Brief Hospital Course:
1. Hypotension/Fever
Initially received broad spectrum antibiotics, stress dose
steriods and aggressive fluid rehydration. Although he required
pressors on admission, he was weaned off after less than 24
hours. Given his recent history of C diff and urine cultures
positive for pseudomonas, he was treated with vancomycin, zosyn
and flagyl empirically. There was no obvious source for
infection; blood cultures as well as PICC line cultures were
negative. During the course of his hospitalization, he devloped
worsening pulmonary edema with anuria, making it difficult to
support his blood pressure with IV fluids.
2. Acute on Chronic Renal Failure
Unclear etiology for acute worsening, perhaps secondary to
volume loss from recent C.diff, possibly secondary to
pseudomonal UTI, though per renal there is possibilty of chronic
pseudomonal colonization of patient's urine. He developed
anuria and was dialyzed by renal. After initiating dialysis,
the patient expressed his wish not to be put on dialysis. He
and his wife, who is his health care proxy, agreed to change
goals of care to make him CMO so that he could go home with
hospice.
3. Pulmonary Edema
Likely multifactorial causes including aggressive fluid
replacement, worsening heart failure, acute renal failure and
possible pseudomonal UTI. Echo demonstrated new wall motion
abnormality; however, upon review of the Echo with cardiology,
the feeling was that the basal wall akinesis was in fact present
on prior TTE. Cardiology was consulted and recommended PA
catheter placement to ellucidate etiology, catheter was not
placed due to comorbidities and change in goals of care.
4. ESRD s/p cadaveric renal transplant
Treated with tacrolimus and prednisone.
5. Metastatic prostate cancer.
Received Lupron
Patient was discharged on [**2138-3-22**] to go home with hospice. He
was given ativan and morphine for symptomatic control.
Medications on Admission:
Tacrolimus 2mg PO BID
Prednisone 10mg PO daily
Vancomycin 250mg PO QID
Lasix 100mg PO BID
Humalog insulin SS
Ferrous sulfate 300mg PO daily
Prevacid 30mg PO Daily
Hexavitamin
Fluoxetine 30mg PO daily
Allopurinol 100mg PO BID
Neurontin 100mg PO QHS
Epogen MWF
Dulcolax, mylanta, tylenol prn
Discharge Medications:
1. Lorazepam 2 mg/mL Concentrate Sig: [**2-12**] ml PO Q4H (every 4
hours) as needed.
Disp:*50 ml* Refills:*1*
2. Morphine Concentrate 10 mg/0.5 mL Solution Sig: 0.5-1 ml PO
every 4-6 hours.
Disp:*25 ml* Refills:*1*
3. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every
6-8 hours.
Disp:*20 Supp* Refills:*2*
4. home oxygen
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice [**Location (un) 270**] East
Discharge Diagnosis:
End Stage Renal Disease
Acute Renal Failure
Heart Failure
Prostate Cancer-Metastatic
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile and
with appropriate follow up.
Discharge Instructions:
You were admitted to the hospital with fever and low blood
pressure. You were treated for a presumed infection. You were
found to have a urinary tract infection which was treated. You
also required dialysis because of your end stage renal disease.
After discussion with you and your wife, it was decided to
pursue comfort measures only and you were discharged with home
hospice.
Please take all medications as prescribed.
Please call your PCP or your nephrologist if you have any
questions.
Followup Instructions:
Call if needed.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2138-3-22**]
ICD9 Codes: 0389, 5849, 5856, 5990, 2762, 4241, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4574
} | Medical Text: Admission Date: [**2140-5-5**] Discharge Date: [**2140-5-14**]
Date of Birth: [**2083-10-9**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 56 year old African
American female with a history of sickle cell disease, gout,
hypertension, diastolic congestive heart failure and chronic
renal failure who was recently admitted [**2140-4-9**], to
[**2140-4-16**], with mental status changes and lethargy, which were
attributed to pain medicines with an element of uremia. She
also developed diarrhea with negative stool cultures and
negative Clostridium difficile toxin times three. She was
discharged home on [**2140-4-16**], and then had a follow-up
appointment in hematology clinic the day of admission with
Dr. [**Last Name (STitle) **]. She was noted to be febrile to 101 and reported
having fevers for the last few days. She also reported
urinary frequency but no dysuria. She complained of pain
over tophi of her bilateral elbows and redness. She was
originally admitted to the [**Company 191**] service on the floor but she
was noted to have a diffuse back and abdominal pain and chest
pain. She was given one liter of D5 normal saline, Ceptaz
and Magnesium, Tylenol and Morphine for pain.
REVIEW OF SYSTEMS: Positive for mild chronic shortness of
breath on home four liters oxygen, no cough, positive
diarrhea times two days, no nausea, vomiting, no bright red
blood per rectum, no melena, no dysuria, no frequency, no
sick contacts. She sleeps with four pillows at baseline and
has had no changes in her weight recently. There was concern
for acute chest given her sickle cell disease and then she
was transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Sickle cell disease, recent pain crisis and admission.
2. Gout.
3. History of poor response to blood transfusions secondary
to immune mediated hemolysis.
4. Chronic renal insufficiency with focal glomerulosclerosis
with a normal baseline creatinine of 3.0 to 4.0.
5. History of increased ferritin with possible secondary to
hemochromatosis.
6. Congestive heart failure with an echocardiogram on [**3-27**],
with an ejection fraction of greater than 55% and diastolic
dysfunction.
7. Depression.
8. Home oxygen, two liters.
9. Hypertension.
10. Anemia.
11. Status post cholecystectomy.
12. Reactive airway disease.
13. Hepatomegaly on CT found on [**2140-4-1**], increased alkaline
phosphatase and GGT secondary to question of chronic
intrahepatic cholestasis.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. once daily.
2. Albuterol one to two puffs q6hours p.r.n.
3. Amlodipine 5 mg once daily.
4. Folate 5 mg once daily.
5. Silvamere 1600 three times a day.
6. Epogen 16,000, however, she has not been receiving this.
7. Sodium Bicarbonate 1300 three times a day.
8. Hydroxyurea [**2137**] once a day.
9. Hydralazine 50 mg q6hours.
10. Lasix 60 mg p.o. once daily.
11. Protonix 40 mg once daily.
12. Actigall 300 mg three times a day.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: She is retired and lives with her daughter.
[**Name (NI) **] tobacco and no alcohol and no intravenous drug abuse.
PHYSICAL EXAMINATION: On admission, temperature 101.6, pulse
113, blood pressure 158/80, respiratory rate 24, oxygen
saturation 100% on four liters. She appeared uncomfortable
and tired. Head is normocephalic and atraumatic. The pupils
are equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Mucous membranes are
moist. No sinus tenderness. The neck was supple with full
range of motion. She was tachycardic with a normal S1 and S2.
Her lungs were clear to auscultation bilaterally with no
wheezes or crackles. Her abdomen was obese, positive bowel
sounds, diffusely tender, positive enlarged liver, 13
centimeter span, no spleen tip, no caput, no fluid ascites
appreciated. She had no costovertebral angle tenderness.
Extremities showed no cyanosis, clubbing or edema. She had
positive warm and swollen left elbow. Cranial nerves II
through XII are intact. Strength is [**5-30**] throughout in all
four extremities. No asterixis.
LABORATORY DATA: White blood cells was 0.8, hematocrit 11.0,
platelet count 81,000. Sodium 139, potassium 2.8, chloride
112, bicarbonate 15, blood urea nitrogen 69, creatinine 3.3,
glucose 121, ALT 22, AST 45, alkaline phosphatase 736, total
bilirubin 0.9, LDH 153, albumin 3.0, calcium 8.2, magnesium
1.3, phosphate 4.0, uric acid 7.9. Reticulocyte count was
pending. ANC was 130. Hepatoglobin 155. Fibrinogen 571.
Chest x-ray demonstrated improvement from prior chest x-ray
on [**2140-4-15**], with a decreased pleural effusion, no focal
infiltrative process, but positive cardiomegaly.
HOSPITAL COURSE: She was admitted to the unit with concern
for acute chest, however, given her febrile neutropenia, she
was placed on Ceftazidime which was renally dosed. She
remained febrile until [**2140-5-8**], three days into admission.
It was thought that there was a possibility of septic
arthritis. Her left elbow was tapped. The second tap
revealed 220,000 white blood cells, 792,500 red blood cells
of which the differential was 92% polys, 3% lymphocytes and
4% monocytes. They were unable to aspirate much from the
joint given the high prevalence of gout crystals. However,
her elbow decreased in size and clinically began to improve.
She did remain afebrile. Additionally, blood cultures also
came back positive for MSSA for which she was changed to
Oxacillin on [**2140-5-9**].
Pancytopenia - This was thought to be secondary to
Hydroxyurea, the dose of which had been escalated recently.
This medication was discontinued and her count began to
slowly improve.
Acute renal failure - She had chronic renal insufficiency.
On admission, her creatinine was 3.3, however, after
aggressive diuresis in the Intensive Care Unit, her
creatinine bumped to as high as 6.7. Renal consultation was
obtained and felt that this was secondary to hypoperfusion
from the diuresis and her creatinine slowly began to recover
and was 4.5 at discharge. The renal team following thought
that she would eventually need hemodialysis and was to set
her up for an outpatient port after discharge.
Pulmonary - The patient had chronic lung disease on home
oxygen, however, chest CT demonstrated multiple infarcts
thought to be secondary to sickle disease. She was also
found to have pulmonary hypertension on echocardiogram. The
etiology of this was also likely to sickle cell disease. She
was set up with an outpatient with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
pulmonary to further evaluate this.
Cardiac - The patient has a tendency to easily go into
congestive heart failure. She is on Lasix at home. Because
of her mild chest pain shortness of breath on admission, she
was ruled out by enzymes on [**2140-5-6**]. The Lasix was
initially held secondary to renal failure. An echocardiogram
on [**2140-5-9**], demonstrated an ejection fraction of 70%,
moderate pulmonary hypertension, left atrial dilatation, left
ventricular hypertrophy, 1+ mitral regurgitation, 2+
tricuspid regurgitation, and her fluid status remained
stable.
Additionally, she had an episode of atrial fibrillation while
in the Intensive Care Unit with rapid ventricular response.
This was responsive to Diltiazem and she remained in normal
sinus rhythm at discharge.
Gastrointestinal - The patient complained of right upper
quadrant chronic abdominal pain. It was thought this was
secondary to iron overload and hemochromatosis. She had
previously been seen by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] during a
previous hospitalization. Therefore, she was set up with an
outpatient appointment to evaluate this for possible biopsy
and kelation therapy.
Gout - It was thought that the left elbow swelling and pain
was secondary to gout, however, she was unable to be
medicated for this as the pancytopenia prohibited her from
Hydroxyurea and Colchicine. There was a question of septic
arthritis. Therefore, Prinivil was also not begun. However,
orthopedic consultation by Dr. [**Last Name (STitle) 284**] felt that there was
no evidence of infection and therefore no indication for
surgery. Therefore, she was started on Hydroxyurea upon
discharge as all her cell lines had normalized at that time.
She had follow-up with Dr. [**Last Name (STitle) **] in hematology clinic to
follow-up this closely.
The patient clinically did very well once transferred out of
the Intensive Care Unit. PICC line was placed and she was
discharged home on intravenous Oxacillin times fourteen days
with home VNA.
MEDICATIONS ON DISCHARGE:
1. Hydroxyurea 1000 mg one tablet p.o. once daily.
2. Oxacillin two grams q6hours for ten days.
3. Celexa 20 mg p.o. once daily.
4. Folic Acid 1 mg p.o. once daily.
5. Thiamine 100 mg p.o. once daily.
6. Pantoprazole 40 mg p.o. once daily.
7. Erythropoietin 10,000 three times a week.
8. Silvamere 800 mg three times a day.
9. Sodium bicarbonate 650 mg three times a day.
10. Diltiazem 60 mg p.o. four times a day.
11. Hydralazine 75 mg p.o. q6hours.
12. Albuterol one to two puffs inhaled q6hours p.r.n.
FOLLOW-UP: Hematology/oncology Clinic with Dr. [**Last Name (STitle) **],
Pulmonary Clinic with Dr. [**Last Name (STitle) **], [**Hospital **] Clinic
with Dr. [**Last Name (STitle) **], and an appointment with her primary care
physician one week following discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 20150**]
MEDQUIST36
D: [**2140-5-15**] 11:36
T: [**2140-5-17**] 20:20
JOB#: [**Job Number 106564**]
ICD9 Codes: 7907, 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4575
} | Medical Text: Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-27**]
Date of Birth: [**2111-10-9**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Aortic Valve stenosis presenting for COREVALVE
Major Surgical or Invasive Procedure:
COREVALVE
History of Present Illness:
Mr. [**Known lastname 112298**] is a 69 year old man with severe aortic stenosis,
CAD s/p stent to mid-LAD and D1 ([**2172**]), HTN, HLD, diabetes,
afib, and CKD, who presented for Corevalve.
Initial workup of his aortic stenosis revealed critical disease
with [**Location (un) 109**] 0.45cm2, mean gradient 55mmHg, EF 55-60%. Cardiac cath
revealed
nonobstructive CAD and patent stent. He was initially referred
for surgical AVR, and 9 weeks ago underwent sternotomy, where
epiaortic ultra sound revealed prohibitively calcified aorta and
procedure was aborted. He was then referred to [**Hospital1 2025**] for
evaluation for TAVR and was found to have large annulus. He was
referred to [**Hospital1 18**] for treatment options. He was again deemed not
a surgical candidate due to heavily calcified aorta. He met all
inclusion criteria for COREVALVE/TAVR and was admitted on [**2181-8-19**]
for the procedure. Upon admission he endorsed SOB after walking
[**12-11**] mile and climbing 4 stairs, lightheadedness when getting out
of bed, and chest pressure when loading the car.
COREVALVE procedure took place the morning on [**2181-8-20**]. The
procedure went well aside from development of LBBB.
On arrival to the floor, patient was intubated and stable.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-Critical aortic stenosis
-Stent to mid-LAD and D1 in [**2172**]
-Afib (sotalol, warfarin)
3. OTHER PAST MEDICAL HISTORY:
-CKD
Past Surgical History:
-sternotomy ([**2181-6-19**])
-rt index finger reattachment s/p trauma
Social History:
Married, lives with wife. Two children. Retired
owner of distributing company (doors and windows). Frequents
summer home in NH. Warfarin managed by [**Hospital3 **] at
[**Hospital3 **] Center, [**Hospital1 1559**]. Has own INR machine at home.
Independent in ADLs.
Race: caucasian
Last Dental Exam: dental clearance obtained - Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 112299**]
(Highland St, [**Hospital1 1559**] MA)
Lives with: wife
Occupation: retired company owner
Tobacco: 60 pack years, quit 20yrs ago
ETOH: [**1-12**] scotch/day
Family History:
Father died age 69- emphysema.
Mother Died age 89 of MI, No heart disease before age 65.
1 nephew with congenital HD
Physical Exam:
ADMISSION EXAM:
VS:T 98, HR 60 (paced) 121/52, RR 15, O2 sat 100% on
GENERAL: WDWN male in NAD, lying comfortably in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Left eye with
injected conjuctiva. Visual acuity intact bilaterally, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVP, pacer wire present in right IJ.
CARDIAC: irregular rate, normal S1, S2. Late Systolic murmur
heard at RUSB radiating thoroughout the precordium. No thrills,
lifts. No S3 or S4.
LUNGS: Well healed sternotomy scar. Resp were unlabored, no
accessory muscle use. CTAB anteriorly, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. + BS No abdominial
bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No hematoma at access
sites
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
[**2181-8-20**] 01:10PM WBC-6.0 RBC-3.84* HGB-11.9* HCT-37.7* MCV-98
MCH-31.0 MCHC-31.5 RDW-14.0
[**2181-8-20**] 01:10PM PLT COUNT-153
[**2181-8-20**] 01:10PM BLOOD Glucose-92 UreaN-30* Creat-1.1 Na-136
K-4.6 Cl-104 HCO3-25 AnGap-12
[**2181-8-20**] 01:10PM ALBUMIN-4.3
[**2181-8-20**] 01:10PM CK-MB-3 proBNP-5523*
[**2181-8-20**] 01:10PM PT-18.5* PTT-35.3 INR(PT)-1.7*
[**2181-8-20**] 01:10PM ALT(SGPT)-23 AST(SGOT)-28 CK(CPK)-86 ALK
PHOS-71 TOT BILI-1.0
2-D ECHOCARDIOGRAM [**2181-8-21**]:
Prevalve Implant
Mild spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. Mild spontaneous echo contrast is present in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There is severe symmetric left ventricular
hypertrophy. 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.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. There is moderate thickening of the
mitral valve chordae. Moderate (2+) mitral regurgitation is
seen. There is no pericardial effusion. Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] were
notified in person of the results.
Postvalve implant
Corevalve seen in the aorticv position. It appears well seated.
There is mild perivalvular leak. Moderate mitral regurgitation
persists. The mean gradient across the mitral valve is 4 mm Hg.
There is some turbulence noted in the LVOT. Rest of the
examination is unchanged
DISCHARGE LABS:
Brief Hospital Course:
ASSESSMENT AND PLAN: 69 yo man with critical symptomatic aortic
stenosis, history of CAD s/p stent to midLAD and D1 [**2172**], HLD,
DM, CKD, afib, HTN deemed not a surgical candidate for
conventional AVR due to heavily calcified aorta, now s/p
Corevalve.
1. Severe aortic stenosis admitted for COREVALVE. Procedure
went well, no complications, pt was extubated in CCU
post-operatively without complications. Right IJ was removed on
POD#2, patient was stable and called out to regular cardiology
floor. His post-op course was overall uncomplicated. However,
he spiked a fever to 101.1 on [**8-23**], blood and urine cultures
were sent and were no growth to date on the day of discharge.
Post-op ECHO on [**8-27**] showed a mildly dilated LA, markedly
dilated RA, moderate symmetric LVH. Hyperdynamic LV systolic
function(EF>75%). There is a mild resting LVOFT obstruction. A
mid-cavitary gradient is identified. An aortic CoreValve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Mild (1+) AR/MR, mild PAH. There is no pericardial
effusion. He will follow-up as planned with Dr. [**Last Name (STitle) **] as an
outpatient.
2. Diastolic heart failure - NYH Class II, LVEF >55%. BNP 55K.
Losartan was restarted once patient was extubated and off
pressors. He was discharged on Losartan, aspirin, simvastatin,
and zetia. Standing diuretic not ordered as hypertrophic heart.
Oral fluids to be encouraged.
3. Atrial fibrillation: went into LBBB and afib during
procedure, but now natively conducting without narrow complex
QRS. Sotalol was held for bradycardia and was not restarted
prior to discharge. He was started on heparin drip while
holding coumadin. The heparin gtt was discontinued, warfarin
was restarted at home dose and he was treated with Aspirin and
plavix until INR therapeutic and then plavix can be stopped.
4. CAD - (stent to midLAD and D1 [**2172**], patent), losartan, ASA,
vytorin and plavix as above.
5. HLD - continue ezetimibe/simvastatin, and heart healthy diet.
Simvastatin dose was reduced secondary to med interaction.
6. HTN - as noted above, he was initially on nitro gtt for
elevated blood pressures and then Losartan was restarted as
above. Plan to resume home benicar dose on discharge.
7. CKD - metformin held during hospitalization, and all meds
were renally dosed. Glipizide 2.5mg started in place of
metformin. Patient to monitor blood glucose at home. BUN/Cr to
be drawn on [**8-29**].
8. DM - home metformin held, and he was started on insulin
sliding scale while hospitalized. Glipizide 2.5mg started in
place of metformin. Patient to monitor blood glucose at home.
BUN/Cr to be drawn on [**8-29**].
9. Eye Pain: When patient was extubated, he complained of eye
pain, likely due to corneal abrasion. Ophthalmology was
consulted and noted corneal abrasion he was tx with
Bacitracin/Polymyxin B Sulfate and Latanoprost 0.005%.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Vytorin [**9-29**] *NF* (ezetimibe-simvastatin) 10-20 mg Oral
daily
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. olmesartan *NF* 40 mg Oral Daily
5. Sotalol 60 mg PO BID
6. Warfarin 2.5 mg PO DAILY16
7. Ascorbic Acid 500 mg PO DAILY
8. Aspirin EC 81 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. coenzyme Q10 *NF* 50 mg Oral daily
11. flaxseed oil *NF* 1,000 mg Oral daily
Discharge Medications:
1. Ascorbic Acid 500 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Vitamin D 800 UNIT PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Clopidogrel 75 mg PO DAILY
Start: In AM day of surgery. Do not give if direct aortic
approach - GIVE PRIOR TO GOING TO OR
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*1
7. GlipiZIDE XL 2.5 mg PO DAILY
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth each
morning Disp #*15 Tablet Refills:*3
8. coenzyme Q10 *NF* 50 mg Oral daily
9. flaxseed oil *NF* 1,000 mg Oral daily
10. Vytorin [**9-29**] *NF* (ezetimibe-simvastatin) 10-20 mg Oral
daily
11. Warfarin 2.5 mg PO DAILY16
check INR daily until stable
12. Outpatient Lab Work
basic chemistry (potassium, sodium, chloride, serum bicarb, BUN,
creatnine) - please draw on Wednesday [**2181-8-29**]
13. olmesartan *NF* 40 mg Oral Daily
14. Artificial Tear Ointment 1 Appl LEFT EYE PRN eye pain
15. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN eye
discomfort/dryness
16. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE
Q8H
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Aortic stenosis s/p CoreValve AVR [**2181-8-21**]
2. CAD s/p PCI to mid-LAD and D1 ([**2172**])
3. HTN
4. Hyperlipidemia
5. Paroxysmal atrial fibrillation (warfarin)
6. T2DM
7. CKD
8. s/p sternotomy ([**2181-6-19**])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Groin restrictions - no lifting >10 lbs x 1 month post procedure
Discharge Instructions:
Mr. [**Known lastname 112298**],
It has been a pleasure working with you in the treatment of
your severe aortic stenosis. You had a prior sternotomy at an
outside hospital in [**Month (only) 205**] of this year for a planned surgical
aortic valve replacement, but was found to have a heavily
calcified aorta upon closer examination. Your surgery was unable
to be done. You were then referred for aortic valve treatment
options and were found to be a candidate for Corevalve/TAVR. You
underwent your procedure on [**2181-8-21**]. Postoperatively you
demonstrated some changes on your EKG [**Location (un) 1131**]. Electrophysiology
specialists were consulted, an EP study was done which
demonstrated no indication for further intervention.
You have progressed nicely and are now ready for discharge
to home with arrangements made for visiting nurses.
You have been provided with separate discharge instructions
regarding the corevalve procedure.
It is important to weigh youself daily!
Notify the doctor if you gain more than 3 lbs in 2 days, or 5
lbs in 5 days.
Followup Instructions:
I understand you already have an appt to see Dr [**Last Name (STitle) 112300**] on [**9-4**].
I understand you already have an appt to see your cardiologist,
Dr [**Last Name (STitle) 47403**].
We will contact you to with information regarding your 30day
followup with Dr [**Last Name (STitle) **]. You will also have an echocardiogram
with that visit.
ICD9 Codes: 4241, 4280, 5859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4576
} | Medical Text: Admission Date: [**2125-9-7**] Discharge Date: [**2125-9-17**]
Date of Birth: [**2100-6-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
cold like symptoms
Major Surgical or Invasive Procedure:
endotracheal intubation
Right internal jugular vein central vein catheter placement
arterial line placement
bronchoscopy
History of Present Illness:
25 yo F with no significant PMH presented to OSH with cold-like
symptoms which progressively worsened to multilobar pneumonia
per report, transferred here for persistent hypoxia requiring
NRB and blood tinged sputum ? need for bronchoscopy.
.
Per report, patient was seen in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] x 2 over this week
with cold like symptoms. Her symptom started on [**9-2**] with body
ache, headache, and mild nasal congestion/rhinorrhea, so she
went to the ED on [**9-3**]. She was discharged with ibuprofen.
Then developed fever up to 102-103 with dry cough, dizziness,
lightheadedness with changing positions. She was noted to be
hypotensive in the ED again on [**9-5**], got IVF, and got admitted.
Since her admission to [**Hospital1 **] medicine floor, she has received
CTX and azithromycin for atypical pneumonia/multilobar
pneumonia. She reports that her ache and HA are gone,
temperature is better, but breathing and cough have worsened
since [**9-5**]. She reports that her sputum is not thick but is
tinged with blood, pink in color. She has a mild sore throat
now. She desatted down to 78-80% on 6L, for which rapid
response was called. Her O2 requirement has gone up over the
last 24 hours, requiring NRB from 2L initially. Given her
leukopenia, persistent fever with Tm 105.3 ([**9-5**]), worsening
hypoxia, patient was transferred to [**Hospital1 18**] for further
management.
.
Of note, patient reports + sick contact in school where multiple
kids have called in sick. No sick contact at home. She lives
in a dorm. Traveled recently to [**Country 14635**] in [**2-/2125**], [**Location (un) **] [**11/2124**],
[**Location (un) 7349**], [**Location (un) 5354**] over the last couple of years. No known TB
exposure.
.
Currently, patient reports feeling somewhat difficult with
breathing, coughing frequently, mild sore throat.
Past Medical History:
- ? h/o reactive airway dz from viral URI, resolved with beta
agonist a few years ago.
Social History:
- moved to the US ([**State 57509**]) from [**Country 14635**] at age 18
- currently a teacher at [**Location (un) 86**] area
- has a younger sister in [**Name Prefix (Prefixes) **]
- [**Last Name (Prefixes) **] live in [**Country 14635**] and are Japanese speaking only
- has a good friend in [**Name (NI) 86**] area who is her contact person
between her and her parents
- Tobacco: [**1-20**] cig x 8 years
- Alcohol: socially
- Illicits: denies
Family History:
- grandfather died of lung disorder NOS, 80
- grandmother with breast cancer
- mother with "problem in the uterus"
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.8 BP: 98/56 P: 90 R: 33 O2: 91% on high flow 95%
FiO2
General: Alert, oriented, mildly tachypneic
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: no wheeze or rhonchi, significant bronchial sound R> L,
frequent dry coughs, + e-> a changes R>L, mild paradoxical
movement with abdomen
CV: borderline tachycardia, normal S1 and S2, no m/r/g
Abd: soft, NT, ND, BS+, no rebound/guarding, no organomegaly
Ext: warm, dry, 2+ DP and PT pulses bilaterally, no edema
GU: no foley
Neuro: no focal weakness, moving all four, able to move to
commode
Discharge Exam:
Vitals: T 98.5 Tm 99.6 HR 70 BP 100/63 RR 18 pOx 98%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Pertinent Results:
Admission Labs
[**2125-9-7**] 11:16PM BLOOD WBC-3.1* RBC-4.17* Hgb-12.6 Hct-34.9*
MCV-84 MCH-30.2 MCHC-36.1* RDW-12.6 Plt Ct-126*
[**2125-9-7**] 11:16PM BLOOD Neuts-82.4* Lymphs-15.9* Monos-1.2*
Eos-0.2 Baso-0.3
[**2125-9-7**] 11:16PM BLOOD PT-11.1 PTT-40.3* INR(PT)-0.9
[**2125-9-7**] 11:16PM BLOOD Glucose-131* UreaN-3* Creat-0.5 Na-139
K-3.4 Cl-106 HCO3-25 AnGap-11
[**2125-9-7**] 11:16PM BLOOD Calcium-8.0* Phos-1.8* Mg-1.7
.
Other labs:
[**2125-9-8**] 12:43PM BLOOD HCG-<5 IS NEGA
[**2125-9-10**] 07:00AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160
[**2125-9-13**] 03:08AM BLOOD dsDNA-NEGATIVE
[**2125-9-12**] 05:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-PND
Echo:
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
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. There is no aortic valve stenosis. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
RUQ ultrasound:
FINDINGS: The liver is normal in appearance with no focal liver
lesion. No biliary dilatation is seen and the common duct
measures 0.3 cm. The portal vein is patent with hepatopetal
flow. There is some sludge seen within the lumen of the
gallbladder; however, no gallstones are identified. The pancreas
is unremarkable but is only partially visualized. The spleen is
unremarkable measuring 11.5 cm. A small splenule measuring 1.9
cm is seen at the inferior tip of the spleen. No hydronephrosis
is seen. The right kidney measures 10.4 cm and the left kidney
measures 11.2 cm. The visualized portion of the IVC is
unremarkable. No AAA is identified. No ascites is seen in the
abdomen. There are right and left pleural effusions.
.
IMPRESSION:
1. Unremarkable son[**Name (NI) 493**] appearance of the abdomen.
2. Right and left pleural effusions.
.
CXR [**2125-9-14**] (Prior to extubation)
COMPARISON: Chest radiographs from [**9-13**], [**9-12**],
[**9-11**] and
[**2125-9-10**].
FINDINGS: The tip of the endotracheal tube is 3.9 cm from the
carina. A
nasogastric tube courses through the esophagus and entering into
the expected location of the stomach but the tip is beyond the
field of view. Bilateral hazy lung opacities are present with
prominence of the pulmonary vasculature bilaterally. Bibasilar
consolidations are present. Bilateral layering pleural effusions
are present. No pneumothorax is present.
.
IMPRESSION:
1. Stable bilateral pleural effusions and consolidations. Stable
support
lines.
.
DISCHARGE LABS:
[**2125-9-17**] 07:00AM BLOOD WBC-8.6 RBC-3.40* Hgb-9.8* Hct-29.6*
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.8 Plt Ct-984*
[**2125-9-17**] 07:00AM BLOOD Neuts-72.7* Lymphs-18.6 Monos-6.9 Eos-1.3
Baso-0.5
[**2125-9-17**] 07:00AM BLOOD Glucose-98 UreaN-11 Creat-0.4 Na-141
K-4.7 Cl-104 HCO3-29 AnGap-13
[**2125-9-17**] 07:00AM BLOOD ALT-92* AST-65* LD(LDH)-337* CK(CPK)-83
AlkPhos-161* TotBili-0.4
[**2125-9-17**] 07:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
[**2125-9-12**] 05:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-BORDERLINE
[**2125-9-12**] 05:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-BORDERLINE
[**2125-9-12**] 05:40AM BLOOD HCV Ab-POSITIVE*
Brief Hospital Course:
Ms [**Known firstname 91468**] is a 25 year old female with no significant PMH who
presented with multilobar pneumonia with hypoxia and increased
O2 requirement requiring intubation for respiratory failure.
.
# RESPIRATORY FAILURE:
Patient was admitted to MICU from the outside hospital. During
her initial hours, she became profoundly hypoxemic requiring
intubation. Clinical picture was consistent with ARDS thought to
be [**12-20**] multilobar pneumonia either [**12-20**] influenza or atypical
organisms. Initial flu swab and cultures were negative. ID was
consulted who suggested sending flu and Mycoplasma PCR.
Mycoplasma pneumoniae PCR was ultimately positive and pt was
transitioned to CTX and azithromycin. She completed a 10 day
course of CTX and was ultimately extubated to nasal canula and
did well. Patient transferred to the floor and was weaned off
nasal cannula. She was ambulatory without any significant
dyspnea, and her lungs were CTAB. She was started on a 14 day
course of azithromycin, which she will complete as an
outpatient. Patient also prescribed Albuterol for resistance
with reactive airways at discharge.
.
# LEUKOCYTOSIS/FEVER:
While intubated patient continued to spike fevers despite broad
spectrum antibiotics. CVL was removed which showed evidence of
purulence. Wound culture and catheter tip culture were both
negative. Additionally, patient developed diarrhea. C. diff
toxin was sent and was negative. Initially when cultures were
negative, a rheumatologic work-up was started which resulted in
a positive [**Doctor First Name **]. Rheumatology was consulted and did not believe
that this was a rheumatologic process.
.
# PANCYTOPENIA:
Initially patient admitted with pancytopenia thought to be [**12-20**]
sepsis/critical illness. Hemolysis was considered and with
elevated LDH was entertained. With treatment of pneumonia,
pancytopenia started resolving upon transfer to floor. Patient
had an increase in all of her cell lines, and was discharged
without leukocytosis.
.
# TRANSAMINITIS:
Thought to be [**12-20**] shock versus mycoplasma infectious process.
Viral hepatitidies negative but had equivocal lab result for Heb
B. Her transaminitis was continually trending down prior to
discharge.
.
TRANSITIONAL ISSUES:
1) Patient did not have PCP prior to admission, she was setup
with a new PCP in [**Name9 (PRE) **] and will have follow-up within 2
weeks post discharge. Patient advised to not return to work
until following Monday.
Medications on Admission:
- ibuprofen 600 mg q8h
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Last dose on [**9-20**].
Disp:*3 Tablet(s)* Refills:*0*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
3. Guaifenesin DM 10-100 mg/5 mL Syrup Sig: [**3-27**] milliliters PO
every six (6) hours as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Mycoplasma Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known firstname 91468**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because of a severe pneumonia (infection in your lungs). You
were treated with antibiotics and improved. You will need to
continue your medication as prescribed (Azithromycin).
MEDICATION CHANGES:
START Azithromycin 250mg Once a day, last day [**9-20**].
START Albuterol inhaler every 6 hours as needed for shortness of
breath
START Guafinesin cough syrup every 6 hours as needed for cough
We have scheduled an appointment for you to see establish care
with a primary care physician. [**Name10 (NameIs) 357**] see below, it is important
that you follow up after your hospitilization.
Followup Instructions:
Department: [**Hospital1 **] FAMILY MEDICINE
When: TUESDAY [**2125-9-25**] at 11:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 88538**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4577
} | Medical Text: Admission Date: [**2120-3-18**] Discharge Date: [**2120-5-10**]
Date of Birth: [**2120-3-18**] Sex: M
Service: Neonatal
HISTORY: Baby [**Known lastname **] [**Known lastname **] is the second twin born at 9:26
a.m. on [**3-18**] at 33-3/7 weeks gestation, admitted through
the NICU for prematurity and respiratory distress. The mother
is a 28-year-old G1 para 0 woman who presented in preterm
labor with rupture of membranes and twin #1.
Mat Prenatal labs: blood type O positive, antibody negative,
GBS unknown, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune.
Delivery via cesarean section for twin pregnancy.
On admisstion to NICU:
BW= 1520 grams (10-25%), HC= 30.5 cm (25-50%), L=42.5 cm (25%)
T= 98.6, HR= 164, BP= 61/31 (41),RR= 72,SpO2 (room air)=89%,
glucose screen= 43.
Adm PHYSICAL EXAMINATION: General exam: Nondysmorphic, mild
respiratory distress. HEENT: Anterior fontanel open and flat,
red reflex present bilaterally, oral pharynx intact.
Clavicles intact. CV: RRR, no murmur, strong femoral pulses.
Respiratory: Fair air entry bilaterally, mild retractions
with occasional grunting. Abdomen soft, nontender,
nondistended, no hepatosplenomegaly. Extremities: Warm, well
perfused, good pulses. Back: Straight, no [**Hospital1 **] or dimples.
GU: Testes descended bilaterally, normal male, patent anus.
Neurologically intact with symmetric tone. Hips: Stable, no
clicks.
LABORATORY DATA:
Initial CBC: Hct=49%, WBC 8.7K (nl diff), Plt 274K.
Initial blood culture= neg. Chest x-ray: wnl.
ASSESSMENT AND PLAN Twin 2:
1. AGA 33-3/7 week twin gestation
2. Respiratory distress.At adm: Rx CPAP= 6sm, FiO2%=25%
3. R/O sepsis: negative. Rx amp/gen x 2 day.
4. Intially NPO: IV fluids: D10W 80 cc/kg/day
HOSPITAL COURSE:
Growth:
Birth date [**2120-3-18**] (Day 0) Discharge date [**2120-5-10**] (Day 53)
GA 33.3 wk Discharge PMA 41 wk
BW 1520 gm Discharge Wt=3030gm
Birth L = 42.5 cm discharge L=50cm
Head Circ = 30 cm discharge HC=36.5 cm
Nutrition:
Began enteral feeds day 4. Began ad lib feeds day 40.
At discharge, infant feeding breast milk 24 cal/oz (breast milk +
4 cal of Neosure powder) ad lib. Weight gain on this regimen for
the past 13 days (day 40 through day 53) averaged ~30-45 gm /day.
Most recently infant's intake = 150 to 200 cc/kg/day.
Each feed is ~3+ oz. Infant may progress to ad lib on demand BM
20 cal and breast feeding within 1 week after evaluation of
weight gain on breast milk 24 cal/oz.
Chemistries:
last electrolytes ([**2120-3-30**])= wnl (Na 137, K 4.3, Cl 107, HCO3 23,
Triglyceride 127.
Bilirubin: Max total bili 8.3/direct 0.3.
Rx phototherapy [**3-21**] - [**3-23**]. Phototherapy restarted [**3-26**] (bili =
6.8/0.3) through [**3-28**].
Respiratory:Rx CPAP day - 0 day 2. Infant's PDA contributed to
increased respiratory distress. Rx with assisted ventilation x 1
day + indomethacin (day 2). Weaned to nasal canula O2 on day
3,weaned to breathing room air day 5. Returned to CPAP (FiO2=21%)
day 8 when infant had s/sx consistent with sepsis. Weaned off
CPAP to breathing room air on [**2120-3-28**] (day 10). Infant breathed
RA with no other respiratory support throughout remainder of NICU
course (day 53).
apnea/ Bradycardia/Desaturation episodes: Caffeine therapy
[**2120-3-26**] (day 8) through [**2120-4-3**] (day 16). Thereafter, bradycardia
was noted 0 to 4 times per day, with feeds, occasionally during
sleep. Bradycardia episodes were self resolving, not requiring
intervention. Pulse oximeter was discontinued [**2120-5-3**]. For 8 days
prior to and includeing day of discharge ([**2120-5-10**]), infant had no
episodes of bradycardia. [**5-4**], [**5-5**], and [**5-10**] infant had 1 episode
on each of these 3 days of isolated self-resolving bradycardia
that did not compromise the baby. [**Name (NI) **] evidence of apnea documented
for at least 8 days. Given the clinical well being of the baby
and the desire to continue cardiac monitoring, the infant will be
discharged to home with cardiac/apnea monitor. (Denmarks Home
Medical ([**0-0-**]). Parents received CPR 2 weeks ago when
twin 1 was discharged home. Parents received cardiac/ apnea
monitoring training in hospital today. VNA will visit home on
[**2120-5-12**]. Pediatrician appointment on [**2120-5-13**].
Cardiovascular: Day 2 ([**2120-3-19**]) ECHO showed PDA= 4.5 mm. Rx with
indocin. PDA resolved following day. Another murmur was noted
with no adverse hemodynamic effects. ECHO ([**2120-4-9**]) revealed no
PDA. Dx PPS (peripheral pulmonary stenosis murmur). This soft
murmur remains at discharge.
Hematology:
1st CBC ([**2120-3-18**]): Hct=49%, WBC 8.7K Plt =274K
2nd CBC ([**2120-3-25**], day 7) when infant developed s/sx c/w sepsis:
Hct 44%, WBC=4.2K (27%N, 30% Bands), Plt 248K.
CBC ([**2120-3-28**],day 10): Hct=38%, WBC=5.9K (48%N, 2%B), Plt=77K. Plt
counts increased. Last plt count = 235K ([**2120-4-1**], day 14).
No blood product transfusion.
[**2120-5-6**]: Hct 28%, Retic 3.5%. Continue Fe supplementation.
Infectious disease:
1st R/O sepsis: neg. Amp/gen discontinued after 2 days.
2nd r/o sepsis: neg blood and CSF cultures. Infant received 9-10
days of Vancomycin, gen, zosyn (days Day 7 - day 15) due to
clinical presentation.
Day 16, infiltrate R foot Rx topical abx. Thrush: Rx with oral
nystatin beginning [**5-4**] (day 47). Continue nystatin oral solution
3 times per day. Pediatrician can decide when to discontinue. No
evidence of diaper moniliasis.
Neurology: No clincial or gestational indication for cranial
ultrasound. Neurological exam is appropriate for premature full-
term equivalent gestational age.
Audiology: Hearing screen ([**2120-4-30**]) passed bilaterally.
Ophthalmology: No clinical or gestational indication to screen
for ROP. Red reflex appears wnl and is present bilaterally.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home with apnea/cardiac monitor. Pediatrician and
family can decide when to discontinue apnea/ cardiac monitor.
Recommend at least 7 days of no documented bradycardia or apnea.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
CARE RECOMMENDATIONS:
Nutrition: As noted above. Continue BM 24 cal/oz for ~1st week
after discharge. Advance to breast feeding as indicated by weight
and infant's ability to breast feed.
Home apnea/ cardiac monitor as noted above.
Medications
Nystatin oral solution: 1 ml 3 times daily. Pediatrician will
decide when to discontinue. include iron or ferrous sulfate 4
mg/kilo and multivitamins 1
ml p.o. q.d.
Iron and vitamin D supplementation: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominantly breast
milk should receive vitamin D supplementation at 200
international units ([**Month (only) 116**] be provided as a multivitamin
preparation) daily until 12 months corrected age.
Car seat position screening: Passed.
State newborn screening status: On [**4-1**], [**Known lastname **]'s newborn
screen was normal.
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria:
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the following:
A. Daycare during RSV season. B. A smoker in the
household. C. Neuromuscular disease. D. Airway
abnormalities or E. School age siblings.
3. Chronic lung disease.
4. Hemodynamically significant congestive heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for household
contacts and out of home caregivers.
Rotavirus: This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital if
they are clinically stable and at least 6 weeks but less than 12
weeks of age.
FOLLOWUP:
1. [**Hospital6 407**]. [**2120-5-12**]
2. Primary pediatrician. [**2120-5-13**]
DISCHARGE DIAGNOSES:
1. Prematurity at 33-3/7 weeks, twin gestation.
2. Mild respiratory distress syndrome. resolved. 3. 3. Mild
Hyperbilirubinemia requiring phototherapy, resolved.
4. Patent ductus arteriosus, s/p Indomethacin. resolved.
5. Cardiac murmur: Peripheral pulmonary stenosis by exam and
echocardiogram.
6. Clinical sepsis requiring 10 days of therapy.
7. Mild hydronephrosis on the right which does not require
VCUG or prophylactic therapy.
8. Infrequent bradycardia that does not appear clinically
significant but still warrants monitoring with home
apnea/bradycardia monitoring.
VACCINES RECEIVED: Hepatitis B vaccine on [**2120-4-15**].
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 62246**]
MEDQUIST36
D: [**2120-5-9**] 17:12:48
T: [**2120-5-9**] 18:26:07
Revised by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2120-5-10**] at 1740.
Job#: [**Job Number 72281**]
ICD9 Codes: 769, 7742, 2875, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4578
} | Medical Text: Admission Date: [**2136-6-19**] Discharge Date: [**2136-7-3**]
Date of Birth: [**2065-11-10**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: A 70-year-old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]
status post prior silent myocardial infarction referred for
outpatient cardiac catheterization after having a positive
exercise tolerance test and recent anginal symptoms.
HISTORY OF PRESENT ILLNESS: A 70-year-old woman with a
history of silent myocardial infarction echocardiogram from
[**2134-4-7**] revealed an ejection fraction of 55% with
distal septal and apical hypokinesis and mildly dilated LV
and mild mitral regurgitation. Over the past several months,
the patient has noticed that she is having intermittent chest
pain, can occur at any time. She has taken sublingual
nitroglycerin in the past with relief of these symptoms. She
has also noticed that she is having shortness of breath with
a minimal amount of walking. She reports occasional
shortness of breath at rest. On [**5-15**] of [**2136**] she had an
exercise tolerance test, 3 minutes [**Doctor First Name **] protocol, 70%
maximum heart rate achieved. She had no chest pain,
electrocardiogram without ischemic electrocardiogram changes.
Imaging revealed a large area of inferior apical infarct with
moderate peri-infarct ischemia. There was left ventricular
dilatation at rest worsening with stress. There was also
septal dyskinesis in the lateral wall, hypokinesis.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post silent myocardial
infarction
2. Hypertension
3. Hypercholesterolemia
4. Noninsulin dependent diabetes mellitus
5. Gastroesophageal reflux disease
6. Cataracts
PAST SURGICAL HISTORY: Bilateral broken ankles, T&A and
dilatation and curettage
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Aspirin 81 mg qd
2. Glucophage 1000 mg [**Hospital1 **]
3. Glucotrol XL 10 mg qd
4. Prilosec 20 mg 3 to 4x a week
5. [**Doctor First Name **] 60 mg [**Hospital1 **]
6. Multivitamin 1 qd
7. Pravachol 40 mg qd
8. Atenolol 50 mg qd
9. Accupril 20 mg qd
LAB DATA PRIOR TO ADMISSION: White count 11.1, hematocrit
30.3, platelets 198. Sodium 144, potassium 4.0, chloride
108, CO2 27, BUN 19, creatinine 0.9.
SOCIAL HISTORY: Divorced. She lives with her son. She is
the caregiver, as the son has cerebral palsy.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization. She was brought to the cardiac
catheterization lab where she underwent cardiac
catheterization. Please see catheterization report for full
details. In summary, catheterization showed an ejection
fraction of 20%, left main 80%, LAD serial 80% to 90%
lesions, left circumflex with diffuse disease and an RCA with
80% lesion. Following the catheterization, cardiothoracic
surgery was consulted. The patient was seen and accepted for
coronary artery bypass grafting. On [**6-22**], she was
brought to the Operating Room at which time she underwent
coronary artery bypass grafting x4. Please see the Operating
Room report for full details. In summary, she had a coronary
artery bypass graft x4 with a left internal mammary artery to
the LAD and saphenous vein graft to OM and ramus sequentially
and saphenous vein graft to the PL. She was transferred from
the Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, she had milrinone at 0.5 mcg per kg
per minute and Neo-Synephrine at 1 mcg per kg per minute.
She did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from the ventilator
and successfully extubated.
On postoperative day 1, the patient was weaned from her
milrinone. She did, however, require Neo-Synephrine to
maintain an adequate blood pressure. Also, on postoperative
day 1, the patient experienced an episode of atrial
fibrillation. At that time, she was started on amiodarone
and electrophysiology was consulted because the patient had
been noted to have sinus bradycardia with a rate of 40 prior
to her surgery. In addition, on postoperative day 1, the
patient's chest tubes were discontinued.
On postoperative day 2, the patient was weaned successfully
from her Neo-Synephrine infusion. The patient remained in
atrial fibrillation and with the assistance of anesthesia the
patient was cardioverted with 150 joules to a sinus
bradycardia with a rate of 35 to 40. She remained in the
Intensive Care Unit, given her relative bradycardia. For the
next several days, the patient remained in the Intensive Care
Unit to monitor her heart rate and rhythm. During that time,
she continued to receive amiodarone and she remained in sinus
bradycardia with a rate between 35 and 55.
On postoperative day 5, it was felt that the patient was
stable and ready to be transferred from the Intensive Care
Unit to Plastics for continuing postoperative care and
cardiac rehabilitation. Postoperative day 7, the patient's
amiodarone was discontinued, given her continuing
bradycardia. On postoperative day 8, the patient was noted
to be in a sinus rhythm with a rate of 55 to 60.
Postoperative day 9, the patient was noted to be back in
atrial fibrillation with a heart rate of 90 to 110. Low dose
beta blockers were started at that time and during the course
of that day, the patient again converted back to a sinus
rhythm with a rate of 70 beats per minute on Lopressor 25 mg
[**Hospital1 **].
After consultation with electrophysiology and given that
patient tolerated her arrhythmias well, it was decided that
there was no urgent indication for intervention on the part
of pacemaker or AICD placement/EP studies. After
consultation with EP and the patient, it was decided to
discharge the patient to a rehabilitation center on low dose
beta blockers and Coumadin with a target INR of 2 and that
the patient would return in one month for EP studies plus or
minus pacemaker and AICD placement.
On postoperative day 11, it was decided that the patient was
stable and ready for discharge to rehabilitation. At the
time of discharge, the patient's physical exam is as follows:
VITAL SIGNS: Temperature 98.6??????, heart rate 75 sinus rhythm,
blood pressure 126/78, respiratory rate 20, O2 saturation 95%
on room air. Her weight preoperatively is 85.8 kg. At
discharge it is 73.1 kg.
LAB DATA ON DAY OF DISCHARGE: White count 11.2, hematocrit
33.2, platelets 371,000. PT of 17.1. PTT is 31.6 and INR is
2.1. Sodium 140, potassium 4.3, chloride 102, CO2 26, BUN
24, creatinine 1.1, glucose 60.
PHYSICAL EXAM:
GENERAL: Alert and oriented x3, moves all extremities,
follows commands.
RESPIRATORY: Breath sounds clear to auscultation
bilaterally.
HEART: Heart sounds regular rate and rhythm, S1, S2, no
murmur.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: Warm and well perfused with no edema.
STERNUM: Stable, incision open to air, clean and dry.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting x4 with left internal mammary artery to LAD,
saphenous vein graft to OM and ramus to sequentially,
supraventricular tachycardia to PL.
2. Hypertension
3. Hypercholesterolemia
4. Noninsulin dependent diabetes mellitus
5. Gastroesophageal reflux disease
6. Cataracts
7. Bilateral ankle fractures
8. Dilatation and curettage
The patient has no known drug allergies.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg [**Hospital1 **]
2. Colace 100 mg [**Hospital1 **]
3. Enteric coated aspirin 325 mg qd
4. Metformin 100 mg [**Hospital1 **]
5. Glipizide XL 10 mg qd
6. Atorvastatin 40 mg qd
7. Metoprolol 25 mg [**Hospital1 **]
8. Regular insulin sliding scale
9. Tylenol 650 mg q4h prn
10. Percocet 5/325 1 to 2 tablets q4h prn
11. Coumadin 3 mg q hs, titrate to a goal INR of 2
FOLLOW UP: The patient is to have follow up with the wound
clinic in two weeks, follow up in cardiology in one month for
EP studies and follow up with Dr. [**Last Name (STitle) 70**] in four to six
weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2136-7-3**] 10:57
T: [**2136-7-3**] 11:24
JOB#: [**Job Number 41494**]
ICD9 Codes: 4111, 9971, 4240, 4280, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4579
} | Medical Text: Admission Date: [**2147-9-19**] Discharge Date: [**2147-9-27**]
Date of Birth: [**2072-5-20**] Sex: M
Service: C-MED Blue
HISTORY OF PRESENT ILLNESS: The patient comes in with chest
pain. He awoke at 4 a.m. in the morning and went to the
bathroom. He returned, and then on returning he had [**6-1**]
chest pressure with radiation to his left arm which he
considers his anginal equivalent. He took two sublingual
nitroglycerin tablets, and the pain resolved. Thirty minutes
later while in bed he had [**9-1**] chest pressure relieved with
one sublingual nitroglycerin. The pain returned in 30
minutes again. This time it was [**10-2**] to [**11-1**] with
diaphoresis. No nausea, vomiting, or shortness of breath.
He called Emergency Medical Service. They brought him to the
Emergency Department at [**Hospital1 69**].
He received three sublingual nitroglycerin in the ambulance
and some morphine, and there was no resolution of the pain.
In the Emergency Department he was given a nitroglycerin drip
and heparin drip and had resolution of his pain. He has been
pain free since. The patient normally can walk several
blocks and greater than a flight of stairs. He has no
paroxysmal nocturnal dyspnea. No orthopnea.
REVIEW OF SYSTEMS: On review of systems he denied headache,
dizziness, shortness of breath, cough, dysuria, nausea,
vomiting, diarrhea. He has a little bit of constipation.
PAST MEDICAL HISTORY: (His past medical history is
significant for)
1. Coronary artery disease with a non-Q-wave myocardial
infarction with 3-vessel coronary artery bypass graft back in
[**2135**]. In [**2144**] had two stents in his right coronary artery.
Back in [**2147-5-23**] he had two stents in his saphenous vein
grafts.
2. He also has had prostate cancer, status post radiation
therapy which had led him to have consistently
guaiac-positive stools.
3. He also has elevated cholesterol.
4. Gout.
5. He has had a right hip replacement.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He does not smoke. He does not use ethanol;
he does not really drink ethanol. No intravenous drug use.
His wife lives in the [**Name (NI) **] Home after having a
cerebrovascular accident back in [**2147-2-23**], which has
been very stressful for the patient over the past few weeks.
FAMILY HISTORY: His father died at the age of 65 from
coronary artery disease. His brother had a myocardial
infarction in his 60s and died. There is also hypertension
in the family.
PHYSICAL EXAMINATION ON ADMISSION: The physical examination
on admission showed a temperature of 97.8, pulse of 50, blood
pressure 122/46, 99% on 2 liters, respiratory rate 13, weight
was 155 pounds to 160 pounds. His head revealed pupils were
equal, round, and reactive to light. Anicteric. Extraocular
movements were intact. The oropharynx was clear and moist.
His neck revealed there was no jugular venous distention.
His neck was soft and supple, and there were no bruits. His
lungs were clear to auscultation bilaterally. His heart had
a regular rate and rhythm. At times he was in sinus
bradycardia, S1/S2. On examination, the patient (Mr. [**Known lastname 1726**])
did have a 2/6 systolic murmur in his right upper sternal
border. Abdominal examination was nondistended. Bowel
sounds were positive. Soft and nontender. Groin revealed
there were no bruits. Extremities revealed no cyanosis,
clubbing or edema. Dorsalis pedis pulses bilaterally. His
genitourinary examination showed guaiac-positive stool.
Cranial nerves II through XII were grossly intact. He was
nonfocal. His sensory was intact. Motor was [**5-27**] in the
upper and lower extremities.
LABORATORY VALUES ON ADMISSION: Laboratory values on
admission showed a first set of creatine kinases were
actually negative at 45, troponin of less than 0.3. His
SMA-7 was unremarkable except for a glucose of 174.
RADIOLOGY/IMAGING: Electrocardiogram showed sinus
bradycardia with first-degree AV block, ST depressions in V4
to V6 which were new.
HOSPITAL COURSE: The patient was admitted. He was ruled
out for a myocardial infarction by enzymes, and he was
subjected to a Persantine thallium test which showed a
moderate reversible inferior wall defect with an ejection
fraction of 65%.
The patient was then taken to catheterization on [**9-21**]
which showed 2-vessel disease with left main coronary that
was normal. The left anterior descending artery was 99%,
occluded left internal mammary artery to left anterior
descending artery was patent. The left circumflex was 80%
proximally occluded, 80% mid before the first obtuse
marginal. The right coronary artery with 50% mid. Two
stents were patent. The saphenous vein graft to first obtuse
marginal was found to be 90% in-stent thrombosis. The
saphenous vein graft to first diagonal showed a 50% in-stent
occlusion, 50% in the saphenous vein graft. Intervention of
the obtuse marginal thrombus was removed and TIMI-III flow
was achieved. Left ventricular ejection fraction was 57%.
Left ventricular end-diastolic pressure was 12, which was
considered normal.
The patient was returned to his hospital bed. On the night
of [**9-21**], he began to experience chest pressure which was
increasing in pain, and so the patient was taken for a
re-look angiography. Again, his second catheterization
totally occluded saphenous vein graft to second obtuse
marginal and third obtuse marginal at the site of prior
intervention earlier that day. In addition, the percutaneous
transluminal coronary angioplasty was complicated by what
appeared to be perforation in the actual native vessel of the
heart which appeared to be the second obtuse marginal; so,
the patient was corrected with tamponade using balloon. The
patient was admitted to the Coronary Care Unit overnight.
Echocardiogram at this time showed no evidence of pericardial
effusion, and echocardiogram on the next morning in the
Coronary Care Unit showed no additional effusions.
The patient was transferred back to the floor on the morning
of [**Last Name (LF) 2974**], [**9-22**]. The patient continued to do experience
chest pain which he has had since his second intervention.
Enzymes drawn that day showed evidence for a myocardial
infarction with a creatine kinase of 1211, 97 MB fraction 8%,
and the next subsequent creatine kinases were 1065, 1213. The
patient also demonstrated ST elevations in his
electrocardiogram. His electrocardiogram actually showed
over time evolving anterolateral non-Q-wave myocardial
infarction. The patient's creatine kinases continued to
trend down from the time of his admission starting on
[**9-22**] after his myocardial infarction.
On [**9-23**] it was noted that his hematocrit had dropped
from the lower 30s to 24%, and the patient also complained of
new onset left shoulder pain; so, the patient underwent a CT
angiography which showed no dissection. The aorta and a CT
of his abdomen and pelvis showed no retroperitoneal bleeds,
no femoral bleeds. He was guaiac was actually negative
indicating no evidence for severe gastrointestinal bleeding.
Moreover, his hemolysis laboratory workup did not show
evidence of intravascular hemolysis. The patient was
transfused with a total of 4 units of blood. His hematocrit
decreased isolated but then began to recover and improve to
the point where on discharge he was below normal but above
30%. It was never determined what the source of the decrease
in hematocrit was.
The patient underwent Physical Therapy after his myocardial
infarction and continued to improve. It was determined later
that his shoulder pain which was ruled out for aortic
dissection turned out was probably related to a fall which he
had not reported against the side wall. There was no loss of
consciousness at the time, and his pain improved with
treatment with Tylenol and nonsteroidal antiinflammatory
drugs.
CONDITION AT DISCHARGE/STATUS: Given that the patient's
course improved after the myocardial infarction with
continuing trending down enzymes, electrocardiogram
resolving, and the patient's overall clinical picture
improved, he was discharged on [**9-27**] in improved status
to the [**Hospital3 2558**] Rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. times 23 more days.
3. Lopressor 50 mg p.o. b.i.d.
4. Mavik 4 mg p.o. q.d.
5. Imdur 30 mg p.o. q.d.
6. Serax 10 mg p.o. q.h.s. p.r.n.
7. Colace 100 mg p.o. b.i.d.
8. Tylenol 650 mg p.o. q.4-6h. p.r.n.
DISCHARGE DIAGNOSES:
1. Non-Q-wave myocardial infarction in the anterolateral
region.
2. Coronary artery disease.
3. Hypertension.
4. Prostate cancer, status post prostatectomy.
CODE STATUS: His code status is still full.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], M.D. [**MD Number(1) 18174**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2147-9-26**] 15:41
T: [**2147-9-26**] 15:58
JOB#: [**Job Number 94615**]
ICD9 Codes: 4111, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4580
} | Medical Text: Admission Date: [**2120-1-7**] Discharge Date: [**2120-1-12**]
Date of Birth: [**2058-6-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is on the
neurosurgery service. The patient is a 61-year-old gentleman
transferred via Med-Flight from [**State 1727**] after having a
generalized tonic clonic seizure lasting 15 minutes. The
patient has a longstanding history of melanoma, diagnosed
Decadron on the day of admission was out chopping wood the
day prior to admission, feeling well without any problems.
Notes he was acting himself and seemed to be zoning out and
then had a generalized tonic clonic seizure, was brought to
[**Hospital 1727**] Hospital and then transferred to [**Hospital1 190**] for further management.
comfortably in bed. Mental status: Alert and oriented times
three. Naming intact. Repetition intact. Appropriate
affect. No frontal release sign. No grasp or stout.
Cranial nerves 2 through 12 intact. Pupils are equal, round,
and reactive to light and accommodation. Strength was [**6-4**]
bilaterally. No drift. Normal bulk and tone with no tremor.
Sensory intact. Deep tendon reflexes 2+/4 bilateral upper
extremities, 3+/4 lower extremities. Coordination intact.
CT scan of the brain shows a 4 cm hemorrhage in the right
femoral lobe adjacent to the metastatic lesion.
The patient was admitted to the Surgical Intensive Care Unit
for close monitoring. [**2120-1-8**] the patient was transferred to
a regular floor. He was awake, alert, oriented times three
following commands. EOMs full. Face symmetric with no
drift. Moving all extremities symmetrically and with full
strength.
He was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2120-1-9**] who recommended
having a tumor resection and evacuation of hematoma followed
by radiation. The
patient on [**2120-1-10**] underwent a right frontal craniotomy for
resection of metastatic lesion without interrupt
complication. Postop the patient's vital signs were stable.
He was afebrile. He was monitored overnight in the Recovery
Room where he remained neurologically stable with stable
vital signs. Postoperative Dilantin level was 8.9. He was
given an extra dose of Dilantin. His Dilantin level on the
day of discharge was 10.8.
He was discharged to home in stable condition on [**2120-1-12**].
His dressing was clean, dry and intact. He was
neurologically intact with no drift, moving all four
extremities. Discharged to home with follow-up for staple
removal in one week and then follow-up with Dr. [**First Name (STitle) **] on
[**2120-1-29**] with tapering Decadron down to 2 mg b.i.d, Dilantin
100 mg three times a day, Zantac 150 mg p.o. b.i.d.
The patient's condition was stable at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2120-1-15**] 16:16
T: [**2120-1-15**] 16:27
JOB#: [**Job Number 41100**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4581
} | Medical Text: Admission Date: [**2171-2-16**] Discharge Date: [**2171-2-22**]
Date of Birth: [**2128-10-21**] Sex: M
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
mediastinal mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 42 y.o male with no PMH who was originally transferred
from [**Hospital 5279**] Hospital for eval and tx of a new mediastinal mass
and PE. Pt reports was in USOH until ~4wks ago when he developed
a fever, non-productive cough, scratchy throat and severe SOB
(+orthopnea and DOE), facial+neck swelling, cyanotic ears/lips,
decreased appetite (wt loss 10-12lbs). He also reports sharp
R.sided lateral chest/rib pain, with occasional radiation down
his R.arm and a dull discomfort in his RUQ. He also reports a
white spot in his R.eye vision, that has since resolved. He
reported 2 episodes of n/v over this 4 wk period. He denies
travel, sick contacts, headache, blurred vision, odynophagia,
dysphagia, palps/d/c/melena/brpbr/dysuria/paresthesias
/weakness/skin rash.
He then presented to [**Location (un) **] Urgent Care [**2171-2-14**] where a
large lung mass was found on CXR. He was then admitted to [**Hospital 5279**]
Hospital.
There, CT chest showed a large [**Location (un) 21851**] invading the
R.mediastinum causing severe compression, but no occlusion of
the SVC. This mass was in contact with the pulmonary artery.
Labs showed AFP 1303, LDH 407, normal B-HCG. CT guided bx showed
malignant cells c/w poorly differentiated carcinoma (ddx
carcinomatosis of immature teratoma within mixed cell germ tumor
or poorly differentiated carcinoma with non-small cell
morphology.
Therefore, pt was transferred to [**Hospital1 18**] for mediastinoscopy and
further care. Pt now being transferred to the [**Hospital Ward Name **] for
the initiation of chemotherapy. Pt will require ICU given
possibility of tumor swelling causing complete SVC occlusion (IR
vs. vasc would need to stent). Onc felt comfortable starting
chemo if no liver lesions. Currently ?defect in falciform
ligament, radiology rec U/S. Pt with pan scan at OSH.
.
Currently, pt reports SOB, facial swelling, and R.arm swelling,
but pain is controlled.
Past Medical History:
none
Social History:
The patient has a significant other of 6+ years.
He worked for [**Doctor Last Name 634**] Electronics at a desk job, with no
particular toxic exposures. He reports that he smoked minimally,
[**1-19**] cigarettes per week, but nothing in >7yrs. He reports [**3-21**]
drinks a week, and denies drug use. He lives in [**Location (un) 3844**].
Family History:
Reviewed and noncontributory for any
malignancies. Mother had two minor strokes
Physical Exam:
VitalsT. 97.6, BP 129/77, HR 107, RR 24 sat 96% on 2L, 1607I/
1600 O
GENERAL: well appearing, anxious, NAD, able to speak in full
sentences
HEENT: nc/at, PERRLA, EOMI, anicteric, MMM, no OP lesions
neck:+facial plethora, neck swelling, supple
CARDIAC: s1s2 rrr no m/r/g
LUNG: b/l ae, no w/c/, decreased BS r.base
ABDOMEN:+bs, soft, +slight TTP Ruq, no guarding/rebound.
EXT: R.UE with ~2+edema, L.UE [**1-19**]+edema. LE without edema, no
c/c.
NEURO: AAOx3, CN2-12 intact, motor [**5-22**]
DERM:no rashes.
Pertinent Results:
[**2171-2-16**] 12:30AM PT-14.7* PTT-50.5* INR(PT)-1.3*
[**2171-2-16**] 12:30AM PLT COUNT-543*
[**2171-2-16**] 12:30AM WBC-8.9 RBC-4.27* HGB-11.1* HCT-34.2* MCV-80*
MCH-26.0* MCHC-32.4 RDW-13.0
[**2171-2-16**] 12:30AM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2171-2-16**] 12:30AM estGFR-Using this
[**2171-2-16**] 12:30AM GLUCOSE-111* UREA N-5* CREAT-0.7 SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2171-2-16**] 09:20AM PT-14.7* PTT-64.8* INR(PT)-1.3*
[**2171-2-16**] 09:20AM CEA-<1.0 AFP-1310*
[**2171-2-16**] 09:20AM HCG-<5
[**2171-2-16**] 09:20AM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.2
[**2171-2-16**] 09:20AM ALT(SGPT)-80* AST(SGOT)-52* LD(LDH)-339* ALK
PHOS-138* TOT BILI-0.2
[**2171-2-16**] 09:20AM GLUCOSE-102* UREA N-5* CREAT-0.7 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2171-2-16**] 02:25PM PT-14.9* PTT-69.8* INR(PT)-1.3*
Chest CT scan Date: [**2171-2-11**] [x] outside film
Impression:
1.) large [**Location (un) 21851**] of the RUL invading the right aspect of
the mediastinum and causing severe compression but not occlusion
of the superior vena cava.
2.) PE involving the LLL artery
3.) Multiple nonspecific mediastinal lymph nodes are seen
without
change, the largest right peritracheal lymph node measuring
9x14,
not enlarged by criteria
.
Other
CT-guided needle biopsy [**2171-2-13**] (by dictation, original report
is
not available): flow cytometry negative for lymphoma, POSITIVE
markers: epithelial, pankeratin, BEREP4; NEGATIVE markers: CK-7,
CK-20, TTF-1, b-HCG, yolk-sac cocktail; impression -
differential diagnosis includes carcinomatosis component of the
immature teratoma within the mixed germ cell tumor and poorly
differentiated carcinoma with a non-small cell morphology.
.
MICROBIOLOGY:
none
.
EKG: ST, TWI III, TWF AVF, biphasic T v4-v6. na, no prior.
.
CXR: IMPRESSION: AP chest reviewed in the absence of any prior
chest imaging. Mediastinum is roughly midline despite a large
right pleural effusion accompanied by a sufficient right lung
atelectasis to suggest that this is a longstanding finding.
Smaller left pleural effusion has a very irregular contour along
the mediastinum posteriorly, which may indicate adenopathy.
Trachea is not particularly displaced and narrowed, so the
extent of
mediastinal mass is not appreciated on this study and would
require
cross-sectional imaging for assessment. With such a study one
can distinguish cardiac tamponade from SVC syndrome, which can
present with great clinical similarity. No pneumothorax. Dr. [**Last Name (STitle) **]
was paged.
.
ECHO [**2171-2-12**] OSH
-normal LV size, EF, RV normal, atrial normal, no valvular abn,
trace MR [**First Name (Titles) **] [**Last Name (Titles) **], impaired LV relaxation. No significant
pericardial effusion.
.
CT abd/pelvis OSH read: focal fatty infiltration is seen within
the liver adj to the falciform ligament. pancreas, spleen,
kidneys and adrenal glands are normal in appearance with
incdiental not of 2.5cm cyst from the lower pole of the
R.kidney, no calcified gallstones seen, no enlarged
intra-abdominal nodes seen. Moderately dilated loops of proximal
small bowel are seen with an abrupt caliber change inteh LUQ
beyond which the small bowel is decompressed. The colon overall
is normal caliber. Pelvis-large amt of stool present in rectum
and pelvic contents are otherwise unremarkable.
CXR [**2171-2-16**]:
AP chest reviewed in the absence of any prior chest imaging.
Mediastinum is roughly midline despite a large right pleural
effusion accompanied by a sufficient right lung atelectasis to
suggest that this is a longstanding finding. Smaller left
pleural effusion has a very irregular contour along the
mediastinum posteriorly, which may indicate adenopathy. Trachea
is not particularly displaced and narrowed, so the extent of
mediastinal mass is not appreciated on this study and would
require cross-sectional imaging for assessment. With such a
study one can distinguish cardiac tamponade from SVC syndrome,
which can present with great clinical similarity.
CXR [**2171-2-21**]:
There is no significant interval change in the large right
pleural effusion, although minimal decrease might be suspected
most likely due to postural changes. The right upper
paratracheal enlargement can be again appreciated.
The left lung is well aerated except for minimal basilar
opacities. The left midline tip is at the level of the mid
portion of left subclavian vein.
Scrotal U/S [**2171-2-18**]:
FINDINGS: There are small bilateral hydroceles. The right
testicle measures
2.45 x 1.93 x 3.54 cm. The left testicle measures 2.53 x 2.51 x
3.33 cm. The echotexture of the bilateral testes is extremely
heterogeneous with diffuse patchy areas of relative hypo- and
hyperechogenicity; however, there is no discrete mass identified
within either testicle. Vascularity within the testes appears
symmetric bilaterally. There is a 2.5-mm left epididymal cyst.
The appearance of the right and left epididymides is otherwise
normal.
IMPRESSION:
1. Diffusely and markedly heterogeneous testicular echotexture
bilaterally
without discrete masses identified. The findings are not
suggestive of a germ cell tumor of the testicle. The
differential diagnosis for the findings is broad, however,
including infectious or inflammatory process, possible drug
effect, or sarcoidosis. A diffuse infiltrative malignancy, such
as lymphoma, cannot be excluded, but if the known mediastinal
mass does not represent lymphoma, this seems unlikely. Clinical
correlation is recommended. MRI could be considered for further
evaluation if etiology remains uncertain.
2. Small bilateral hydroceles.
3. Tiny left epididymal cyst.
CT Head [**2171-2-20**]:
FINDINGS: There is no acute hemorrhage, edema, masses, mass
effect, or large territorial infarcts. No enhancing intracranial
lesions are seen. The
intracranial vessels enhance symmetrically, with no evidence of
large vessel cutoff.
Mucosal retention cysts are seen in the right ethmoid, left
maxillary, and
left sphenoid sinuses. The remaining paranasal sinuses and
mastoid air cells are clear. There are no fractures or
suspicious osseous lesions in the skull.
IMPRESSION: No evidence of intracranial metastases.
MRI Abdomen/Pelvis:
FINDINGS: On localizer images and coronal imaging, the known
large right
mediastinal mass is partly visualized. A large right pleural
effusion is
identified with areas of heterogeneous high signal on
T1-weighted images,
suggestive of proteinaceous or hemorrhagic components. There is
extensive
atelectasis of the right lower lobe.
Image quality is markedly degraded by patient's difficulty
suspending
respiration. A subcapsular area of signal loss is identified on
out-of-phase imaging in the anterior aspect of segment IVb of
the liver compared to the in-phase images, appearing to
corresponding to the focal area of low attenuation identified on
CT performed at outside hospital [**2171-2-11**]. The lesion exhibits
low signal in comparison to the adjacent hepatic parenchyma on
fat-suppressed T1 imaging, and is difficult to characterize on
post-contrast imaging due to motion artifact. No other focal
parenchymal lesions are seen in the liver. The portal vein and
hepatic veins are patent.
No intrahepatic or extrahepatic biliary duct dilatation is
identified. The
gallbladder is unremarkable in appearance. No gross abnormality
is seen in
the pancreas, spleen, kidneys or adrenal glands, but views are
suboptimal due to motion artifact. The arteries are suboptimally
visualized in arterial phase imaging, but the celiac artery and
superior mesenteric artery are patent. No free fluid is seen in
the upper abdomen. There is anasarca of the abdominal wall. No
abnormal signal is identified within the visualized bone marrow.
Multiplanar 2D and 3D reformations provided multiple
perspectives for the
dynamic series with kinetic information.
IMPRESSION:
1. Suboptimal visualization of the liver and other abdominal
organs due to
patient difficulty suspending respiration.
2. Area of abnormal hypoattenuation identified on CT likely
corresponds to an area of focal fatty infiltration, but precise
characterization cannot be made due to motion artifact. A repeat
MR study may be considered when the patient's respiratory status
improves.
3. Partial visualization of large right mediastinal mass and
large
right-sided pleural effusion with probable proteinaceous or
hemorrhagic
component.
RESULTS REPORTED AFTER DISCHARGE:
Cytology results
Right lung, fine needle aspirate and cell block
(CN-10-[**Numeric Identifier 85984**], procedure date [**2171-2-13**]):
POSITIVE FOR MALIGNANT CELLS,
consistent with a poorly differentiated epithelioid
neoplasm.
Note: The specimen consists of groups of pleomorphic
epithelioid cells with vesicular chromatin, small nucleoli
and scattered mitoses. See also corresponding core biopsy
report S10-4792 for further characterization.
Pathology results:
Right lung mass, needle core biopsies (CN-10-172, [**2171-2-13**],
[**Hospital 5279**] Hospital, [**Location (un) 5450**], NH):
Poorly differentiated adenocarcinoma, see note.
Note: Tumor cells are positive for keratin and BER-EP4, and
negative for TTF-1, PLAP, calretinin, CD30, CK20, and CK7. AFP
and HCG show high background. Limited tissue available for
study. The tumor shows focal mucin production and rare signet
ring cells. A metastatic lesion should be considered.
Brief Hospital Course:
Pt is a 42 y.o male with no PMH who presented with
SOB/fever/cough/weight loss/SOB and was found to have SVC
syndrome and a mediastinal mass.
#SOB/mediastinal mass-As per oncology note, differential
diagnosis includes carcinomatosis pattern of germ cell-teratoma
vs. poorly differentiated non-small cell. Chemotherapy started
in house day 1: [**2171-2-16**] with regimen of Dexamethasone 20 mg IV
DAILY Duration: 5 Doses, CISplatin 40 mg IV Days 1, 2, 3, 4 and
5, Etoposide 195 mg IV Days 1, 2, 3, 4 and 5. Pt tolerated
chemotherapy very well without evidence of tumor lysis syndrome.
Pt briefly started on ctx and azithro to cover post-obstructive
PNA on [**2171-2-16**], however, these were discontinued on [**2171-2-17**]
given no e/o PNA. He had minimal side effects of nausea which
was well controlled with Ativan, Zofran and standing Compazine.
CEA was <1 and CA [**80**]-9 was within normal at 4. HCG was <5.
Patient's alpha fetal protein level was 1310 on [**2-16**] and 1286 on
[**2-22**], leading the oncology team to be concerned that he would
need a different regimen as an outpatient, including possible
Bleomycin. Metastatic work-up did not reveal disease in the
head or abdomen though there were abnormal CT abdomen findings
as attached. A testicular ultrasound found only heterogenous
abnormalities, if anything, most consistent with lymphoma. For
final pathology and cytology, please see results section.
#SVC syndrome-caused by mass. Pt noted to have compressed SVC
on imaging, but without complete occlusion. Pt was treated with
heparin drip and transitioned to Lovenox. Neck and upper
extremity edema improved over course of admission, as did
headaches and vision changes. Cough was still present at
discharge.
#pulmonary emboli-Noted on outside hospital CT. Pt was
maintained on heparin as above. PE was thought to be most likely
from malignancy.
#transaminitis-noted on labs. Etiology could include malignancy
vs. infection vs. medication effect. Could also be due to
R.sided heart failure vs. metastatic process. CT abdomen
revealed focal fatty infiltration near the falciform ligament.
#anemia-unclear baseline. Could be due to malignancy.
# CODE: full confirmed.
# CONTACT: girlfriend [**Name (NI) 2270**] at [**Telephone/Fax (1) 85985**] or [**Telephone/Fax (1) 85986**]
cell. Pt reports she is HCP.
# Dispo: Patient to f/u with Dr. [**Last Name (STitle) 13551**] in [**Location (un) 3844**] on [**2-26**]
and with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] as needed after that.
Medications on Admission:
MEDICATIONS: none at home;
Meds on transfer:
Docusate Sodium 100 mg PO BID
1000 mL LR
Continuous at 50 ml/hr Order date: [**2-16**] @ 0950
Heparin IV
Alprazolam 0.5-1 mg PO/NG TID:PRN anxiety
Omeprazole 40 mg PO DAILY Orde
Azithromycin 500 mg PO/NG Q24H
CeftriaXONE 1 gm IV Q24H
zolpidem 5mg qhs
.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Primary:
- germ cell-teratoma of the mediastinum
- superior vena cava syndrome
- pulmonary embolism
Discharge Condition:
mentating well, ambulating independently
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from [**Hospital 5279**] Hospital for evaluation and treatment of a mass in
your chest that was obstructing the veins in your neck. You
also have a blood clot in your lungs. The blood clot and
obstructing of the veins in your neck were caused by a cancer in
your chest. You were in the intensive care unti and started on
chemotherapy. You were transfered to the regular oncology
floor. The swelling decreased and you started to feel better.
While you were here you were started on multiple new
medications. They are all of those on the attached list.
Be sure to take the Compazine (Prochlorperazine) even when you
are not nauseous in order to prevent nausea.
Followup Instructions:
You will follow-up on: [**2-26**] at 9:30am.
You will probably have to have your blood checked for alpha
fetal protein at that time.
You will also receive paperwork in the mail to return to Dr.
[**Last Name (STitle) 13551**].
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 85987**] MD
Address: NH ONCOLOGY-HEMATOLOGY
200 TECHNOLOGY DR
[**Last Name (STitle) 85988**] [**Numeric Identifier 85989**]
Phone: [**Telephone/Fax (1) 19102**]
You should call Dr.[**Name (NI) 31162**] office at [**Hospital1 **] if
different therapy is needed. Her number is, ([**Telephone/Fax (1) 31163**].
You will have to have your labs checked on Friday [**3-1**] and faxed
to:
Att: Dr. [**Last Name (STitle) 13551**] at ([**Telephone/Fax (1) 85990**]
Att: Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 38948**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4582
} | Medical Text: Admission Date: [**2143-4-7**] Discharge Date: [**2143-4-18**]
Date of Birth: [**2065-11-14**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
endotracheal intubation
Central venous line placement in R internal jugular
EEG
History of Present Illness:
77F with DM2, HTN, h/o CVA admitted to MICU after being
unresponsive at NH. Per their note, pt was found unresponsive
at 6:45P sitting in a chair. Had refused all her morning meds
and was agitated, then took all of her meds at 5PM. FS was 160
at 4PM, then was 274 at time of unresponsiveness. Pt was
recently discharged from [**Hospital1 18**] with PNA and UTI. Pt is
currently intubated and cannot give a history.
In the ED, glucose initially in the 30s. Given Narcan x2 and
glucose without response. Pt was intubated, presumably for
airway protection, and R IJ was placed. CVP was noted to be
[**3-22**]. LP was performed and was negative. Head CT showed no ICH
or mass effect. CXR and UA were negative. CT abdomen showed no
acute abnormalities. Pt was given glucagon 1mg, D50, Narcan x2,
fentanyl 100mg x2, Versed 2mg x2, vancomycin 1g, and ceftriaxone
1g. Rec'd 2L NS.
Past Medical History:
-Vasculitis: possible giant cell arteritis per right temporal
artery biopsy [**2142-4-30**], Necrotizing granulomatous arteritis,
consistent with giant cell arteritis/polymyalgia rheumatica
vasculitic syndrome. Stains for acid-fast bacilli and fungi are
negative (on prednisone at home); negative antidsDNA, Sm, RNP,
Ro, La, histone, IgG levels, C3, C4, SPEP, ANCA; [**Known firstname **] 1:40
diffuse, elevated ESR. Maintained on prednisone, currently
being tapered.
-Pleural and pericardial effusions, abdominal seroma: extensive
malignancy w/u including pelvic US, mammogram and colonoscopy in
[**3-21**] all negative; fluid collections from all these sources
negative for malignancy and infection.
-Hypertension
-Hypercholesterolemia
-DM: Diet controlled, last HbA1C in [**2142-11-16**] 6.2%
-Alzheimer's disease
-Depression
-History of atrial fibrillation with RVR on ECG in [**2140**]
-Diverticulosis
-History of +PPD in the past: CXR and PPD in [**2142-2-14**] was
negative; currently on INH and pyroxidine to prevent
reactivation while on steroids
-Microcytic anemia: previous iron studies consistent with anemia
of chronic disease and superimposed iron deficiency
-Chronic left shoulder pain: DJD by xray
-History of bacteremia treated with vancomycin and unasyn
-Atrophic vaginitis
.
Past Surgical History:
-Left sided VATS on two occasions ([**Month (only) 956**] and [**2142-3-17**]) for
pericardial and pleural effusion; pericardial window during
[**2142-1-17**] procedure
-Status post TAH with BSO in [**2127**]
-Status post ventral hernia repair in [**2131**]
Social History:
Widowed for over 20 years. Three sons. One is institutionalized
as a result of paranoid schizophrenia. Came to [**Location (un) 86**] in [**2126**]
from [**Country 3587**] to live near her sons. She was one of 7
children. Owned and worked in a variety store in [**Country 3587**];
has not worked since arriving in US. Currently living with son
at home in addition to having around-the-clock service at home.
No alcohol, drug or tobacco use.
Family History:
Brother with diabetes type 2 complicated by extensive peripheral
vascular disease and amputation. Son with paranoid
schizophrenia. Two additional sons in good health.
Physical Exam:
VS: 96.2 (after Bair hugger) 140/80 74 17 100% AC
500x16/0.5/5
RSBI 58.8
Gen: opens eyes to voice, NAD, intubated and sedated
HEENT: PERRL, no JVD; R IJ in place
CV: RRR, nl S1/S2, no m/r/g
Pulm: clear anteriorly
Abd: soft, obese, NT/ND, +BS
Ext: trace edema, good distal pulses, warm
Pertinent Results:
EKG: 60bpm, LBBB, TWI in I, avL, V6 (old), ?
pseudonormalization of T in V5; ST elevations more pronounced in
V2-V4 (4mm vs 2mm in old EKG)
repeat EKG here: ST elevations back to baseline, V5 with TWI -
overall, no change from old EKG
.
[**2143-4-6**] 08:37PM GLUCOSE-28* LACTATE-1.2 NA+-144 K+-3.2*
CL--113*
[**2143-4-6**] 08:37PM TYPE-ART PO2-244* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1 INTUBATED-NOT INTUBA
[**2143-4-6**] 09:15PM PT-13.5* PTT-32.8 INR(PT)-1.2*
[**2143-4-6**] 09:15PM PLT COUNT-410
[**2143-4-6**] 09:15PM WBC-14.8* RBC-3.36* HGB-10.4* HCT-31.2*
MCV-93 MCH-31.1 MCHC-33.4 RDW-16.9*
[**2143-4-6**] 09:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-4-6**] 09:15PM ALBUMIN-2.9* CALCIUM-8.9 PHOSPHATE-4.2
MAGNESIUM-2.3
[**2143-4-6**] 09:15PM CK-MB-22* MB INDX-6.4* cTropnT-0.02*
[**2143-4-6**] 09:15PM LIPASE-34
[**2143-4-6**] 09:15PM ALT(SGPT)-30 AST(SGOT)-30 CK(CPK)-344* ALK
PHOS-51 AMYLASE-46 TOT BILI-0.3
[**2143-4-6**] 09:15PM GLUCOSE-305* UREA N-30* CREAT-1.6* SODIUM-142
POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-24 ANION GAP-12
[**2143-4-6**] 09:46PM URINE RBC-0-2 WBC-[**2-18**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2143-4-6**] 11:40PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-66*
POLYS-5 LYMPHS-72 MONOS-23
[**2143-4-6**] 11:40PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-2* POLYS-2
LYMPHS-81 MONOS-17
[**2143-4-6**] 11:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-57*
GLUCOSE-77 LD(LDH)-46
[**2143-4-7**] 04:08AM GLUCOSE-142* UREA N-25* CREAT-1.1 SODIUM-142
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-21* ANION GAP-13
.
.
EEG Study Date of [**2143-4-15**]
This 24-hour EEG telemetry captured no electrographic
seizures or interictal epileptiform discharges. The background
was
mostly slow and disorganized in the theta frequency range
throughout the
recording suggestive of mild encephalopathy.
.
ECHO [**2143-4-11**]
The left atrium is normal in size. There is symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. There is no pericardial
effusion. Suboptimal image quality - patient unable to
cooperate.
.
CT ABDOMEN [**2143-4-7**]:
No acute intra-abdominal pathology identified. Stable anterior
abdominal wall fluid collection.
.
DISCHARGE LABS:
[**2143-4-18**] 12:45PM BLOOD WBC-13.6*# RBC-3.64*# Hgb-11.5*#
Hct-35.4*# MCV-97# MCH-31.6 MCHC-32.4 RDW-17.5* Plt Ct-592*#
[**2143-4-15**] 06:10AM BLOOD Neuts-77.6* Lymphs-16.2* Monos-5.6
Eos-0.3 Baso-0.3
[**2143-4-12**] 06:50AM BLOOD Hypochr-1+ Anisocy-1+ Macrocy-2+
[**2143-4-18**] 12:45PM BLOOD Glucose-103 UreaN-15 Creat-0.8 Na-149*
K-4.1 Cl-112* HCO3-23 AnGap-18
[**2143-4-10**] 06:11AM BLOOD CK(CPK)-50
[**2143-4-18**] 12:45PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
Brief Hospital Course:
77 year old [**Location 7972**] speaking female with a history of
Alzheimer's dementia, recent admit with pneumonia/UTI in the
setting of delirium, who was admitted with hypoglycemia and
unresponsiveness in the setting of increased antipsychotics
during her prior hospitalization.
.
# Poor PO intake:
Pt not swallowing food past mouth, complaining of throat pain to
son. On exam, throat without evidence of candiasis or
ulceration. Speech and swallow eval revealed that patient is not
intiating swallowing which may be due to progression of the
dementia, complicated by side effects of prior antisychotics.
Discussed options for nutritional support with son, including DC
home with PO intake vs PEG tube placement. Son prefers [**Name2 (NI) **] route
and at rehab need to ensure pt takes PO with supervision and
encouragement.
.
# Delta MS:
Likely med induced from psychotropic medications. EEG
consistent with encephalopathy but no seizure acitivity.
Olanzapine and gabapentin were discontinued, haldol was
restarted per psych at a low dose. No infectious etiology was
found, though she did have several days of C diff negative
diarrhea (as below). UA, CXR, CT head, LP were negative. A 1:1
sitter was used throughout her hospitalization. Psychiatry was
consulted and she was started on haldol which was later switched
to seroquel prn with addition of aricept. Pt experience presumed
extrapyramidal side effects with the haldol exhibiting stiffness
and drooling. Mental status on discharge was improved with
patient alert, oriented, conversing with family members in
[**Name2 (NI) **].
.
# Leukocytosis:
No current evidence of infection; with negative UA, CXR, CT head
and LP. She initially had diarrhea, so was treated with empiric
flagyl until C Diff was negative x 3. She remained afebrile.
Elevated WBC count most likely from prednisone.
.
# Giant Cell Arteritis/Vasculitis:
The patient was continued on prednisone 10 mg PO QD. Her slow
taper will resume as an outpatient. She was continued on INH
and pyridoxine given history of +PPD on prednisone.
.
# ? aspiration:
Speech and swallow was consulted. She was initally NPO with tube
feeds via NG tube, but advanced to nectar thick/ground solids as
her MS improved. Her NG tube was discontinued on [**4-8**].
.
# Elevated CK w/ MB but normal MBI:
This was thought to be [**1-18**] rhabdomyolsis as the patient remains
sedentary, somnolent. CKs increasing during early admission
with elevated MB, troponin 0.02 to 0.03. EKG no change,
difficult to interpret with baseline LBBB. Echo was done; no
WMA found. CK's then trended down.
.
# Hypertension:
BP remained elevated at times in SBP 160s range. Continued on
Metoprolol and lisinopril.
.
# Diabetes Mellitus:
Patient is diet controlled at home. Covered by ISS in hospital.
Currently on prednisone, so blood sugars will need to be
closely moniotred four times daily. Blood sugars well
controlled during admission.
.
# Positive PPD:
Continue INH and pyridoxine supplementation for a total of nine
months from initiating prednisone.
.
# Left thyroid lobe lesion:
New finding on CT scan last admission. Will need outpatient
thyroid US to
better evaluate nodule. TSH within normal limits.
.
# Nodule on R arm:
Patient with Cellulitis of R arm during previous admission,
improved with course of Abx but nodule remains. US [**4-2**] was
inconclusive. Will need outpatient MRI for evaluation in the
future.
.
# Anemia:
HCT at baseline. On iron and folate.
.
# Hypernatremia:
Due to poor PO fluid intake and was treated with IV free water
with good response. Will need further monitoring.
.
# PPX:
Hep SQ TID, PPI
.
# DISPO:
Discharged to [**Hospital **] Healthcare.
Medications on Admission:
ASA 81mg daily
colace 100mg tid
heparin SC
iron sulfate 325mg tid
folate 1mg daily
isoniazid 300mg daily
metoprolol 25mg [**Hospital1 **]
mag hydroxide 30ml po q6 prn
gabapentin 100mg tid
omeprazole 20mg daily
senna 2 tabs qHS
pyridoxine 50mg daily
prednisone 10mg daily
mirtazapine 30mg qHS
lisinopril 30mg daily
Oscal + D tid
risendronate 35mg qMon
olanzapine 2.5mg [**Hospital1 **]; 2.5-5mg prn
levofloxacin 250mg daily - last day [**2143-4-9**]
metronidazole 500mg tid - last day [**2143-4-9**]
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
(3 times a day).
2. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
7. Donepezil 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
8. Isoniazid 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 4 weeks.
10. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a
day) as needed.
11. Pyridoxine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Iron (Ferrous Sulfate) 325 (65) mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO once a day.
13. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
14. Lisinopril 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Os-Cal 500 + D 500-200 mg-unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO
three times a day.
16. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: SLIDING
SCALE Injection ASDIR (AS DIRECTED).
18. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Failure to thrive
Altered mental status
Vasculitis, giant cell arteritis
Anemia
Hypernatremia
Hx of positive PPD
Discharge Condition:
Stable, afebrile, alert, ambulating, tolerating PO.
Discharge Instructions:
During this admission you have been treated for a change in
mental status. You had difficulty feeding on your own and
required supervision with encouragement.
Followup Instructions:
Please followup with your PCP [**Name Initial (PRE) 176**] 1 week for further medical
management.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD
Phone:[**Telephone/Fax (1) 7976**]
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2143-4-22**] 1:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 1690**] Date/Time:[**2143-5-1**] 2:15
ICD9 Codes: 2760, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4583
} | Medical Text: Admission Date: [**2153-12-27**] Discharge Date: [**2154-1-9**]
Date of Birth: [**2153-12-27**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Doctor First Name **] was born at 34
and 5/7 weeks gestation to a 30 year old, Gravida VII, Para
III now IV woman. Mother's prenatal screens were blood type
B positive, antibody negative, Rubella immune, RPR
nonreactive; hepatitis surface antigen negative and group B
strep unknown. This pregnancy was complicated by preterm
labor at 32 and 1/7 weeks gestation and the mother presenting
with contractions. Tocolysis was successful with magnesium
sulfate. During this admission, the mother received
Clindamycin and also Betamethasone. This prenatal course was
also significant for polydipsia and polyuria, diagnosed by
the renal service as nephrogenic diabetes insipidus, related
to Lithium use with super imposed primary polydipsia.
Her previous medical history is remarkable for chronic pain
with multiple triage visits for abdominal pain; a history of
intravenous drug use; negative urine toxicology screens
during pregnancy; last documented cocaine use in [**2153-4-26**].
Smoking a half pack per day during pregnancy. Mother with
bipolar disorder, receiving Lithium and Trazodone currently.
The mother presented in preterm labor on the day of delivery.
She delivered vaginally with Apgars of seven at one minute
and eight at five minutes. The infant's birth weight is 2,535
grams. Birth length is 47.5 cm and the birth head
circumference is 30.5 cm.
PHYSICAL EXAMINATION: Admission physical examination reveals
a preterm infant with decreased tone and activity, improving
gradually after admission. No respiratory distress.
Anterior fontanel open and flat. Palate intact. Heart with
regular rate and rhythm, no murmur. Breath sounds clear and
equal. Abdomen soft, nontender, nondistended. Three vessel
umbilical cord. Normal female genitalia. Stable hip
examination.
HOSPITAL COURSE: Respiratory status: [**Doctor First Name **] has always
remained in room air. She has had some apnea of prematurity.
She has one to three episodes every 24 hours, some requiring
stimulation and some self resolved. She has never required
caffeine treatment.
Cardiovascular status: [**Doctor First Name **] has remained normotensive
throughout her Neonatal Intensive Care Unit stay. There are
no cardiovascular issues.
Fluids, electrolytes and nutrition: Enteral feeds were begun
on the day of delivery and advanced without difficulty to
full volume feeding. At the time of transfer, she is eating
Enfamil 24 calories per ounce on an ad lib schedule, taking
approximately 150 cc per kg per day. At the time of
discharge, her weight is 2,445 grams. Her length was 47 cm
and her head circumference is 30.5 cm.
Gastrointestinal: [**Doctor First Name **] was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life three
until day of life five. Her peak bilirubin occurred on day of
life number three and was total of 12.4, direct of 0.3.
Hematology: She has never received any blood product
transfusions during her Neonatal Intensive Care Unit stay.
Her hematocrit at the time of admission was 53.9.
Infectious disease: Blood culture at the time of delivery
was negative. She received no antibiotics during this
Neonatal Intensive Care Unit stay.
Sensory: Audiology: Hearing screen was performed with
automated auditory brain stem responses and the infant passed
in both ears.
Psychosocial: Mother has been followed by [**Hospital1 346**] social worker, [**Name (NI) **] [**Name (NI) **], beeper
#[**Numeric Identifier 45733**]. Mother is currently residing in Project Cope, a
residential substance abuse program in [**Location (un) **], MA. She is
currently on medication for bipolar disease and receives a
great deal of counseling and support at her residential
program. She will be taking the infant back to live at the
program with her. Two of her other children live with their
respective fathers and one child is in the custody of DSS.
She hopes to obtain custody of that infant within several
months. She has been visiting frequently despite some
significant transportation challenges. She has been very
eager to participate in the infant's care and has followed
through with plans for infant care teaching here in the
Neonatal Intensive Care Unit. She is followed by a
psychiatrist at [**Hospital1 69**],
[**Known lastname **] [**Last Name (NamePattern1) **], extension [**Numeric Identifier 38536**]. She also has a DSS worker,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52561**], telephone number [**Telephone/Fax (1) 52562**].
The infant is discharged in good condition. The infant is
transferred to [**Hospital3 52563**] for continuing
care.
PRIMARY PEDIATRIC CARE: Provided by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 8071**] of
[**Hospital1 3597**], telephone #[**Telephone/Fax (1) 43314**].
CARE AND RECOMMENDATIONS:
Feedings: The infant is taking 24 calorie per ounce formula
on an ad lib schedule.
The infant is discharged on medications for diaper rash,
Criticaid Ointment.
The infant did have an episode of desaturations to the 60's
with her first car seat position screening test and it is
recommended that this test be repeated prior to discharge.
STATE NEWBORN SCREEN: Sent on [**2153-12-30**] and will be sent prior
to discharge on the 14th.
The infant received her first hepatitis B vaccine on [**2154-1-3**].
RECOMMENDED IMMUNIZATIONS:
Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria:
1.) Born at less than 32 weeks.
2.) Born between 32 and 35 weeks with two of three of the
following: Day care during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
school age siblings.
3.) With chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 5/7 weeks gestation.
2. Sepsis, ruled out.
3. Apnea of prematurity.
4. Status post hyperbilirubinemia of prematurity.
5. Contact dermatitis of diaper area.
6. Complex social situation.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 52564**]
MEDQUIST36
D: [**2154-1-8**] 11:13
T: [**2154-1-9**] 04:54
JOB#: [**Job Number 52565**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4584
} | Medical Text: Admission Date: [**2134-11-26**] Discharge Date: [**2134-12-10**]
Date of Birth: [**2051-9-1**] Sex: F
Service: MEDICINE
Allergies:
Peanut / Chocolate Flavor / Codeine
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
CC:[**CC Contact Info 95464**].
Reason for MICU transfer: respiratory distress/COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD and RA who presented
to the ED with developing LLE erythema over 3 days duration.
Presented to PCP who suggested she go to the ED for further
eval. Denied any associated Sx including fever/chills or pain.
Does describe weeping from the lesion. In the ED she developed
afib with RVR and was treated with IV and oral metoprolol and
admitted to medicine for further work-up of new afib.
.
On the floor, she was continued on metoprolol for afib. She was
treated with ceftriaxone for cellulitis but blood cultures
turned positive for strep viridans. Thus, a TTE was ordered
which showed possible aortic valve vegetation. A TEE was
performed today to better characterize the vegetation but during
the procedure she became stridorous.
.
She was treated with nebulizers and IV steroids for presumed
COPD exacerbation. She also had magnesium, furosemide x1, and
metoprolol IV x 2. She was placed on a NRB with saturations in
the 90% and transfered to the MICU for further management of her
respiratory distress.
Past Medical History:
- Osteoporosis with T8-9 compression fracture
- RA
- COPD (no PFTs in OMR)
- HTN
Social History:
Not presently employed. Lives independently. Has a niece who is
[**Name8 (MD) **] RN. No EtOH, tobacco or other drug use.
Family History:
Father with [**Name2 (NI) **]
Physical Exam:
On Admission:
VS: afebrile, BP 114/70, HR 150s, RR 30s, O2sats 93-99% NRB
GA: AOx3, severe increased work of breathing with use of
abdominal muscles for respiration, no sentence dyspnea
HEENT: JVP elevated to 10-12 cm
Cards: irregularly irregular, S1 and S2, +[**1-31**] murmur best heard
over apex
Pulm: intermittent inspiratory stridor, expiratory wheezes
bilaterally, no crackles
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: erythema and flaking on skin over left tibia
extending down to foot. RLE with e/o venous statis changes.
On Discharge:
VS: 97.0 121/77 86 22 94%2L
Gen: Severely kyphotic, elderly female in NAD. Oriented x3.
Mood, affect appropriate.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi. Does have rhoncorous upper
airway sounds.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: venous stasis changes in lower extremity; cellulitis is
significantly improved
Pertinent Results:
On Admission:
[**2134-11-26**] 04:15PM BLOOD WBC-6.9 RBC-4.03* Hgb-12.6 Hct-38.9
MCV-97 MCH-31.3 MCHC-32.4 RDW-12.5 Plt Ct-428
[**2134-11-28**] 08:10AM BLOOD PT-12.2 PTT-22.6* INR(PT)-1.1
[**2134-11-26**] 03:30PM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-145
K-3.5 Cl-105 HCO3-32 AnGap-12
[**2134-12-4**] 08:32AM BLOOD ALT-28 AST-24 LD(LDH)-158 AlkPhos-80
TotBili-0.3
[**2134-11-27**] 06:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
On Discharge:
[**2134-12-10**] 05:45AM BLOOD WBC-10.4 RBC-3.35* Hgb-10.6* Hct-32.4*
MCV-97 MCH-31.5 MCHC-32.6 RDW-13.6 Plt Ct-236
[**2134-12-9**] 05:50AM BLOOD PT-14.5* PTT-30.7 INR(PT)-1.4*
[**2134-12-10**] 05:45AM BLOOD Glucose-102* UreaN-16 Creat-0.4 Na-139
K-4.0 Cl-100 HCO3-36* AnGap-7*
[**2134-12-10**] 05:45AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1
Studies:
.
[**11-30**] TTE: IMPRESSION: Aortic valve mass, probably a vegetation.
No associated aortic regurgitation. Moderate mitral and
tricuspid regurgitation
.
[**12-1**] TEE Esophagus was successfully intubated with TEE probe.
Prior to the acquisition of any pictures the patient developed
stridorous breathing which resolved fully following removal of
the TEE probe. The procedure was aborted at that time. The
patient was closely monitored in the TEE room until sedation
wore off and she fully recovered back to baseline. There was no
further stridor noted.
.
[**12-4**] CT Head: IMPRESSION: No acute intracranial process; exam
limited by exclusion of the superior-most aspect of the brain.
.
[**12-5**] CT Chest: IMPRESSION: 1. No pneumonia. 2. Mild pulmonary
edema. Moderate right and small left pleural effusions,
moderately severe bibasilar atelectasis. New moderate
cardiomegaly. 3. New severe multilevel thoracic vertebral
compression fractures.
.
[**12-9**] CXR: PFI: Improved appearance of right lung with residual
right cardiophrenic consolidation with trace right pleural
effusion; unchanged retrocardiac consolidation with small left
pleural effusion.
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD
and RA who presented with cellulitis and afib with RVR in the
ED. Found to be bacteremic on the floor and found to have aortic
valve vegitation.
.
# Strep viridans bacteremia - The patient initially presented
with cellulitis of her left leg and was treated with oral
antibiotics. On Day #3 of therapy, [**12-29**] blood cultures drawn at
admission returned (+) for Strep Viridans. She was started on IV
ceftriaxone on [**2134-11-29**]. The patient underwent TTE which
revealed an aoritc valve vegitation. Plan was for TEE however,
during the procedure, the patient became stridorous (as
described in detail below) and required intubation and MICU
transfer. In the MICU, the patient underwent TEE which again
demonstrated the aortic valve vegitation. On [**2134-12-8**], the
patient was HD stable and was able to return to the medicine
floor from the MICU. A midline was placed for long term
antibiotic therapy. The patient will be discharged to a rehab
center where she will continue antibiotic therapy for 1 month
and follow-up with ID as an outpatient.
.
# Respiratory distress: On [**2134-12-1**] a TEE was attempted
however had to be abandoned as the patient became stridorous
during the procedure. Following this event, the patient was
stable on the floor until ~6pm when she began to develop
respiratory distress. Despite agressive measures including IV
steroids, nebs, O2, lasix, and racemic epi the patient required
intubation and was transferred to the MICU. In the MICU the
patient was diuresed further and continued on
albuterol/ipratropium for COPD. Was also started on methylpred
60 mg q8h. Imaging showed a mild left effusion and atelectasis.
Extubated on MICU day #1 without event. During her ICU course,
the patient would intermittently develop respiratory distress
and stridor, with saturations dipping into the low 80s. She
underwent BiPAP intermittently overnight, then was changed to
nasal BiPAP after her respiratory status improved. On the floor,
the patient self-discontinued BiPAP due to discomfort. Seen by
ENT who scoped to the level of the vocal cords but found no
abnormality. Etiology of respiratory decompensation is unclear
although is believed to be related to possible upper airway
edema exacerbated by TEE/intubation. Also has poor reserve with
underlying COPD and severe kyphosis.
.
# Afib with RVR - The patient was noted to be in afib with RVR
while in the ED. No known h/o afib. In the hospital she was
initially controlled with IV metoprolol and loaded with orals.
Oral metoprolol titrated to 200mg daily and converted to long
acting. Given CHADS2 score of 2, anti-coagulation was
recommended and the patient was agreeable. Started on warfarin
without bridge and will continue warfarin on an outpatient
basis. Goal INR [**1-28**].
.
# Osteoporosis - In house, the patient was incidentally found to
have a number of new compression fractures on imaging. Is
writted for alendronate, vitamin D, and calcium at home although
reports not reliably taking the alendronate. She was maintained
on calcium and vitamin D in house. Received Alendronate on
Mondays per home schedule. She never complained of pain related
to compression fractures.
.
# COPD - The patient carries a history of COPD. This may have
contributed to respiratory decompensation described above. In
house she was continued on standing nebulizer therapy. Prior to
discharge, the patient continued to have a dry, hacking cough
and an increased oxygen requirement (2L NC to maintain sats
~94%). Given relatively clear imaging, a COPD exacerbation was
suspected and the patient was discharged with plans to complete
a steroid taper and a 5 day course of azithromycin.
.
# HTN - The patient has a h/o HTN and was on atenolol at home.
This was changed to metoprolol in house and she will be
discharged with plans to continue metoprolol.
.
# RA - Has a history of what is apparently rather severe RA. Not
on any medications to control disease at home. Attempted to
contact the patient's rheumatologist although he has apparently
recently retired.
.
# Transitional Issues:
1) Continue Ceftriaxone to complete a 1 month course and
follow-up with infectious disease clinic as scheduled.
2) Recommend referral to see a new rheumatologist (former
rheumatologist retired) and a pulmonologist.
3) Continue Metoprolol 200mg daily for atrial fibrillation
4) Continue coumadin daily and follow-up with [**State 95465**] [**Hospital 2786**] clinic
5) Complete steroid taper and course of azithromycin
Medications on Admission:
MEDICATIONS: (at home)
ALENDRONATE - 70 mg Tablet Weekly
ATENOLOL - 25 mg Daily
FLUTICASONE [FLOVENT DISKUS]
meloxicam 15 mg Tablet Daily
OXYCODONE-ACETAMINOPHEN [ROXICET] - 1 tab Q6H;PRN for pain
MULTIVITAMIN
.
MEDICATIONS: (on transfer)
Ipratropium Neb 1 NEB IH Q6H:PRN SOB/Wheezing
Acetaminophen 325-650 mg PO/NG Q4H:PRN pain or fever
Albuterol Inhaler [**12-27**] PUFF IH Q4H:PRN wheezing/shortness of
breath MethylPREDNISolone Sodium Succ 125 mg x1
Aspirin 81 mg PO/NG DAILY
Metoprolol Succinate XL 200 mg PO DAILY
Alendronate Sodium 70 mg PO QMON
Metoprolol Tartrate 5 mg IV x2
Metoprolol Tartrate 25 mg PO/NG ONCE
Benzonatate 100 mg PO TID
Magnesium Sulfate 2 gm IV ONCE
CeftriaXONE 1 gm IV Q24H day 1 [**11-26**]
MethylPREDNISolone Sodium Succ 125 mg IV Q6H start [**12-2**]
Docusate Sodium 100 mg PO BID
PredniSONE 40 mg PO/NG DAILY
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Racepinephrine 0.5 mL IH ONCE x2
Furosemide 20 mg IV ONCE
Senna 2 TAB PO/NG HS
Guaifenesin [**5-4**] mL PO/NG Q4H:PRN cough
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Monday.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please follow up with your [**Hospital 2786**] clinic for further
management of your dosing.
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once
a day: Please continue on Ceftriaxone until instructed otherwise
at your infectious disease clinic follow-up.
6. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day:
Continue 4 pills daily for 3 days. Then 3 pills daily for 3 days
then 2 pills daily for 3 days then STOP.
Disp:*28 Tablet(s)* Refills:*0*
7. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
10. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: Two
(2) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cellulitis, Atrial Fibrillation, respiratory failure
Cellulitis, Atrial Fibrillation, Endocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!
You were admitted with a skin infection of your leg. In the
emergency room you were also found to have an abnormal heart
rhythym called atrial fibrillation. You were treated with
antibiotics for the skin infection with improvement. You were
also treated with a medication to slow your heart rate and were
started on a blood thinning medication to prevent stroke.
Additionally, you were found to have an infection of your
bloodstream and of your heart valve. For this you will be
discharged on a 4 week course of intravenous antibiotics.
See below for changes to your home medication regimen:
1) Please START Metoprolol 200mg once daily
2) Please START Warfarin 0.5mg in the evening. You will
follow-up with the [**State **] Square-[**Hospital1 18**] office
[**Hospital 2786**] clinic for further changes to your dosing
3) Please CONTINUE Ceftriaxone until otherwise instructed by the
infectious disease clinic
4) Please START Aspirin 81mg DAilY
5) Please STOP Atenolol
6) Please CONTINUE Prednisone 4 pills daily for 3 days. Then 3
pills daily for 3 days then 2 pills daily for 3 days then STOP.
7) Please CONTINUE Azithromycin 250mg daily for 3 additional
days to complete a 5 day course
8) Please STOP Roxicet
See below for instructions regarding follow-up care:
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2134-12-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow-up with your primary care phsyician ([**Doctor Last Name 2204**],
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Telephone/Fax (1) 2205**]) within 7 days of discharge from your
rehabilitation facility.
Completed by:[**2134-12-13**]
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4585
} | Medical Text: Admission Date: [**2187-8-3**] Discharge Date: [**2187-8-8**]
Date of Birth: [**2108-5-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Iodine / Ibuprofen
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
"Feeling unwell"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname **] is a pleasant 79 year old female with history TIA's,
hypertension, and hyperlipidemia who presented to the ED feeling
unwell.
.
She reports she was in her usual state of health, active all day
including completing her water aerobics, and then developed some
shortness of breath and pain across her chest. EMS was called
and she received four 81 mg of aspirin en route.
.
In the ED, initial vital signs were: temperature of 101.0, blood
pressure of 184/92, heart rate 94, respiratory rate 32-36, and
oxygen saturation of 94% on non-rebreather (84% on room air).
She received a sub-lingal nitroglycerin and 4 mg of zofran, 1
gram of ceftriaxone, and 500 mg of PO azithromycin. Systolic
blood pressure trend was initially 184->173->136->98->95. Once
her blood pressure trended down, she was initiated on IV fluids,
and received about 1000 mL. She was eventually weaned from
non-rebreather to 4 liters nasal cannula. She did not require
CPAP. Denied any difficulties breathing, chest pain or nausea.
Past Medical History:
- Hypertension
- Hyperlipidemia
- History of pancreatitis
- Lumbar radiculopathy status-post laminectomy
- Status-post bilateral hip replacements
- History of aspiration pneumonias
- History of TIA
- Impaired fasting glucose, insulin resistance--noted elsewhere
in chart that she has had post-prandial hypoglycemia
- Parathyroidectomy/thyroid nodule resection
- Cervical radiculopathy
- Status-post: tonsillectomy, cholecystectomy, hysterectomy
** Denies any history of cardiac disease including CHF or CAD.**
Social History:
Independent for ADL's, ambulates with cane. Lives above family
in two-family house. No alcohol, tobacco, or drugs. Retired
nurse.
Family History:
Non-contributory.
Physical Exam:
VS: Tm 98.3 / BP 123/67 (123-142/60-70) / HR 76 (76-80) / RR 19
(16-19) / SpO2 96%2L (90-96%RA)
GEN: NAD
HEENT: NCAT, EOMI, PEERL, MMM, oropharynx clear
CV: RRR, no M/R/G
Resp: minimal bibasilar crackles, no wheezes or rhonchi
Abd: soft, obese, NT/ND, normoactive BS, no HSM
Ext: no c/c, LLE 2+ pitting edema w/ decreased sensation
compared to right leg. LLE 4/5 strength, RLE 5/5 strength. b/l
upper extremities equal strength and sensation.
Pertinent Results:
Labs on discharge:
[**2187-8-8**] 06:30AM BLOOD WBC-6.7 RBC-3.93* Hgb-12.3 Hct-36.4
MCV-93 MCH-31.2 MCHC-33.7 RDW-14.0 Plt Ct-134*
[**2187-8-8**] 06:30AM BLOOD Glucose-101* UreaN-11 Creat-0.9 Na-146*
K-3.8 Cl-111* HCO3-27 AnGap-12
[**2187-8-7**] 06:50AM BLOOD CK(CPK)-126
[**2187-8-8**] 06:30AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
Troponins remained negative.
Chest xray showed mild congestive heart failure and underlying
consolidation.
Brief Hospital Course:
# Hypoxic respiratory distress:
Patient arrived in respiratory distress. Initially felt to be
CHF by ED staff, and given sub-lingual nitroglycerin, especially
given chest pain, hypertension, and CXR findings. Had elevated
CK to 500s; normalized during hospital course. Cardiac fractions
were never elevated. Negative troponins, no EKG changes noted.
Given fever in ED and CXR appearance, ICU staff felt the patient
more had community-acquired pneumonia and she was started on
ceftrixone and azithromycin. Patient improved on antibx
treatment (improved leukocystosis, afebrile).
.
# Hypotension:
Differential includes medication-related secondary to
nitroglycerin versus sepsis from pulmonary process. Developed
pressure as low as 87/50 on the unit and her home
anti-hypertensive medications were held. Lactate also trended
down (4.0->2.5). Patient responded well to IVF hydration alone.
UOP, which had dipped down to 10cc/hr, improved with hydration.
.
# Chest pain:
Patient complained of chest pain in the ED. At the time,
differential included coronary artery disease (no known history,
though has known vascular disease including CVA in past) and
pneumonia, among other causes. Troponins were consistently
negative. No EKG changes suggestive of ischemia. CK was
elevated but normalized; MB fraction was not elevated. Daily
ASA was started and continued.
.
# History of hyperlipidemia/TIA: Continued statin and aggrenox.
Medications on Admission:
- Avapro 300 mg
- Aggrenox [**Hospital1 **]
- Lipitor 80 mg daily
- Metoprolol 50 mg [**Hospital1 **]
- Ecotrin 325 mg
- Multivitamin daily
- Chlorthalidone 12.5 mg 3-5 times a week
- Amlodipine 2.5 mg daily
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*4 Tablet(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*8 Tablet(s)* Refills:*0*
6. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with shortness of breath. A chest x-ray
revealed evidence of pneumonia. You were treated with
antibiotics and supplemental oxygen. You will require several
more days of antibiotics once you leave the hospital.
Please note the following changes in your medications:
- Please START azithromycin 250mg, take one daily for 4 days
- Please START cefpodoxime 200mg, take one tablet twice daily
for 4 days.
- Please STOP taking chlorthalidone and amlodipine until seeing
Dr. [**Last Name (STitle) 172**]
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14973**] (one of Dr.[**Name (NI) 8156**] group)
[**Street Address(2) **]. [**Location (un) **], MA
[**Telephone/Fax (1) 133**]
[**8-15**] at 1:00 pm
Department: NEUROLOGY
When: MONDAY [**2187-11-12**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2187-8-9**]
ICD9 Codes: 486, 5849, 2762, 4019, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4586
} | Medical Text: Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-19**]
Date of Birth: [**2125-1-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Fiberscopic intubation
Tracheostomy [**2194-6-17**]
Post-pyloric dobhoff placement [**2194-6-18**]
PICC line placement [**2194-6-18**]
History of Present Illness:
69 yo male with h/o asthma, OSA, pulmonary HTN, HTN, and DM who
woke up yesterday morning feeling like he was getting a cold. He
says he felt similar to how he did prior to his last admission.
He has been feeling chills, tired, and short of breath. He has
had one day of non-productive cough. He has not had any sick
contacts. [**Name (NI) **] has been taking all of his medications and tried to
use his inhalers with no improvement in his symptoms. He uses
his oxygen intermittently during the day but does use his bipap
at night. According to his wife he has been more disoriented for
the last 2 days. He states he has not had any increased edema
recently but his wife says he seems to be more swollen to her.
He denies orthopnea, PND, no increased salt intake recently. He
has not had any recent chest pain, nausea, vomiting, or
abdominal pain. He has not had any urinary pain, frequency or
urgency.
.
In the ED he was found to have an O2sat in the 60s. He was
placed on a NRB and had intermittant hypoxia to the 70s, then
improved to the 90s. He was treated with Combivent nebulizer,
Solumedrol, Lasix 20mg IV X2, and Levofloxacin 750mg IV X1.
.
He was recently admitted to the [**Hospital1 756**] ICU for respiratory
failure secondary to presumed viral pneumonia. He has been seen
frequently in pulmonary clinic and has had an increasing O2
requirement.
Past Medical History:
Past Medical History:
1. Asthma, pulmonary HTN, and severe OSA at home on 3L at
baseline and 4L with exertion, according to him his home sat is
92-95%, previously trached.
2. HTN
3. DM
4. Hyperlipidemia
5. PUD
6. CHF - diastolic heart failure (documented on Echo in [**2192**])
Social History:
Social history: Lives with his wife, used to work in Demolition,
Never smoked, no EtOh, no IVDU
Family History:
Family history: Father had an MI at 49, Mother with MI at 44,
Brother with MI at 75
Physical Exam:
VS: Temp 98.0, Pulse 90, BP 139/75, RR 29, 89% on 50% FM
Gen: alert, oriented, cooperative male in mild respiratory
distress, not using accessory muscles
HEENT: MMM, OP clear, PERRL
Neck: JVD at 5cm above sternoclavicular notch, no
lymphadenopathy
Lungs: Crackles bilaterally at the bases, no wheezing
CV: decreased cardiac sounds, nl S1S2, no murmer
Abd: obese, non-tender, non-distended, positive BS
Ext: 2+ edema on left, 1+ edema on right
Neuro: grossly intact
Pertinent Results:
Imaging: CXR [**6-16**]
Mild interstitial edema and moderate cardiomegaly are stable.
Lung volumes remain quite low, so that focal opacification at
the right lung base could be either atelectasis or pneumonia.
Region of right juxtahilar previously questioned as pneumonia on
[**6-14**] is no longer present and may have been fissural pleural
effusion, since at least a small right pleural effusion is
present. ET tube is in standard placement and a nasogastric
tube passes into the stomach and out of view. No pneumothorax.
.
Echo [**2194-6-10**]:
The left atrium is elongated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The ascending aorta is moderately dilated. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is no systolic anterior motion of the mitral
valve leaflets. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe symmetric left ventricular hypertrophy with
preserved left ventricular function and suggestion of increased
left ventricular filling pressures. Inability to fully visualize
right ventricle due to suboptimal image quality.
.
[**2194-6-18**]:
CHEST, ONE VIEW: Comparison with [**2194-6-17**], 15:50 p.m. New
right PICC is seen looping in the axillary vein and terminating
at approximately the junction of the axillary and subclavian
veins. No pneumothorax. Tracheostomy tube and nasogastric tube
remain in place. Low lung volumes and an improving appearance of
pulmonary vascular congestion. Left lower lobe atelectasis
remains. Please note that the left extreme costophrenic angle
was excluded from this study.
.
[**2194-6-12**]:
[**2194-6-12**] 3:09 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2194-6-14**]**
GRAM STAIN (Final [**2194-6-12**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2194-6-14**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2194-6-12**] 11:27 pm BLOOD CULTURE Source: Line-a line.
**FINAL REPORT [**2194-6-18**]**
AEROBIC BOTTLE (Final [**2194-6-18**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2194-6-18**]): NO GROWTH.
.
[**2194-6-17**] 6:30 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2194-6-19**]**
GRAM STAIN (Final [**2194-6-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2194-6-19**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2193-6-19**]:
CBC: WBC 6.0, Hct 44.3, plt 189
Chem 10: Na 141, K 2.4, Cl 93, CO2 41, BUn 40, creat 0.9. Ca
8.6, Mg 2.0, phos 3.3
Brief Hospital Course:
# Respiratory failure - hypercarbic/hypoxemic, appeared to be
[**2-21**] CHF by evidence of volume overload on CXR, also contributed
by his OSA and pulmonary HTN. Was initially treated with nebs
and steroids, but with little improvement. He was intubated
urgently by fibroscope (difficult airway) for
hypoxic/hypercarbic respiratory failure. In the interim, was
diuresed with IV lasix. He began spiking temperatures on [**2194-6-12**]
and there was concern that this may be a vent-associated PNA. He
was started empirically on Vanc and Zosyn for broad coverage. He
was then discovered to have MRSA PNA in his sputum, so zosyn was
discontinued and vancomycin was continued for a planned 2-week
course (end date [**2194-6-26**]). Given his diastolic CHF, OSA,
pulmonary HTN, ongoing PNA, he was difficult to wean from the
ventilator and plans were made for a tracheostomy. The patient
was transferred to the [**Hospital Ward Name **] MICU and underwent a trach by
IP on [**2194-6-17**] without any complications. He also received a
post-pyloric Dobhoff and a PICC line for long-term antibiotics
on [**2194-6-18**]. The vent setting was weaned off to [**10-29**] (ABG
7.46/61/156) which can be further weaned to a eventual trach
mask at the rehab. Of note, his baseline PCO2 is in 60-70s.
.
# CHF - patient was diuresed while in-house and responded well
to 80 mg IV bid of lasix, with goal I/O even to -500 cc at this
point. His TTE during this admission confirmed diastolic CHF,
with a normal EF>55% and elevvated PCWP. He was ruled out for an
AMI during this admission given his multiple RF and was
continued on ASA, BB, Ace-I. Pt was initially aggressively
diuresed and then required lasix 200mg [**Hospital1 **] to maintain even I/O
daily. He was also started on standing KCL for hypokalemia from
diuresis. His K needs to be monitored and make any KCL changes
if needed to avoid hyper/hypokalemia.
.
# DM - on [**Hospital1 9889**] and Glucotrol as an outpatient, was maintained
on a RISS while in-house for tighter control. Recommend
continuing this until patient at goal with his tube feeds, then
can possibly resume oral agents.
.
# Hyperlipidemia - Continue on Lipitor
.
# Hypertension - continued on b-blocker, ACE-I. BB was titrated
up for better BP control as pulse allowed. CCB was held during
his course, but with BB increase, his BP was well controlled.
If he were to become more hypertensive, consider adding CCB.
# FEN - tube feeds via NGT initially and then post-pyloric
Dobhoff was placed after tracheostomy. Tube feeding goal was
started per nutrition recs. Pt will need speech and swallow
evaluation at the [**Hospital1 **]. Please adjust KCL/prn to
avoid hypo/hyperkalemia while getting lasix.
.
# PPx - PPI, bowel regimen, SC Heparin then can d/c heparin
until fully ambulatory at the rehab.
.
Full code - per discussion with patient
.
Communication with wife - [**Name (NI) 4115**] - [**Telephone/Fax (1) 37036**]
Medications on Admission:
Albuterol
Lisinopril 40mg 1-2 times per day
Nifedipine 90mg daily
Lovastatin 20mg QHS
HCTZ 25mg daily
Toprol XL 100mg Daily (sometimes takes [**Hospital1 **] per his wife)
[**Name (NI) 9889**] 8mg daily
Aspirin 81mg Daily
Discharge Medications:
1. Lovastatin 20 mg Tablet Sustained Release 24 hr [**Name (NI) **]: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
2. Senna 8.6 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Albuterol 90 mcg/Actuation Aerosol [**Name (NI) **]: Four (4) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Name (NI) **]: Four (4)
Puff Inhalation every six (6) hours.
5. Metoprolol Tartrate 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID
(3 times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: 5000 (5000)
units Injection TID (3 times a day): until fully ambulatory.
7. Docusate Sodium 50 mg/5 mL Liquid [**Name (NI) **]: One Hundred (100) mg
PO BID (2 times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
10. Furosemide 80 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times a
day).
11. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]:
Four (4) Capsule, Sustained Release PO DAILY (Daily).
12. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): while still on ventilation.
14. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for aggitation: while still on
ventilation.
15. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 7 days: until [**2194-6-26**].
16. Regular Insulin
Per sliding scale attached
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Primary diagnoses:
MRSA pneumonia
CHF exacerbation
Pulmonary hypertension
obstructive sleep apnea
.
Secondary diagnoses:
Diabetes mellitus
Hypertension
Hyperlipidemia
Discharge Condition:
Stable. Vent setting PS 10/5
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] if you develop any
chest pain, shortness of breath, fevers, chills, diarrhea, or
any other worrisome symptoms.
.
Take medications as instructed and keep your follow-up
appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2194-6-27**] 10:50
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2194-6-27**] 11:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2194-6-27**] 11:10
ICD9 Codes: 4280, 5180, 4168, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4587
} | Medical Text: Admission Date: [**2197-9-3**] Discharge Date: [**2197-9-12**]
Service: FENARD ICU
HISTORY OF PRESENT ILLNESS: Eighty-year-old male admitted
[**9-3**] for nausea, vomiting, and diarrhea. Apparently had
been on Augmentin in the past for foot infection. Upon
arrival to the ED found to be hypotensive, but responding to
IV fluids. Started on Vancomycin, levofloxacin, and Flagyl.
Admitted to the floor, where he had a relatively
uncomplicated course for the first few days. Stool came back
positive for Clostridium difficile and he was treated for
that.
On [**9-9**] p.m., patient became acutely confused and had
declining mental status. Gas drawn at the time revealed a pH
of 7.17 believed to be related to metabolic acidosis. Also
found to be hypotensive at the same time. He was intubated
for continued respiratory acidosis. Was started on Dopamine
and transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. CAD status post CABG.
2. Ischemic cardiomyopathy with an EF of 20-30% with severe
MR.
3. Dual lead pacemaker.
4. Chronic renal failure.
5. Right hip repair in [**Month (only) 216**] of this year.
6. Left cataract surgery.
MEDICATIONS UPON TRANSFER:
1. Levofloxacin 250 p.o. q.d.
2. Vancomycin 500 mg q 4 hours.
3. Zofran.
4. Bumex 2 p.o. b.i.d.
5. Senna.
6. Colace.
7. Atrovent.
8. Albuterol.
9. Digoxin 0.25 Monday and Friday.
10. Metoprolol.
11. Flagyl 500 p.o. t.i.d.
12. Trazodone.
13. Zocor.
14. Flomax.
15. Enalapril 10 mg p.o. q.d.
16. Neurontin 300 mg p.o. q.d.
17. Lopressor 12.5 mg p.o. b.i.d.
PHYSICAL EXAM UPON ARRIVAL TO THE ICU: Weight 57 kg.
Temperature 98. Blood pressure 120/40. Heart rate of 80.
General: Sedated and intubated. Fair air movement with
crackles throughout. Unable to appreciate JVD. S1, S2, [**1-19**]
holosystolic murmur. Abdomen is soft, nontender, and
nondistended, normoactive bowel sounds. Extremities reveal
profound anasarca.
LABORATORIES ON ADMISSION: Significant for a white count of
11.2, hemoglobin 31, platelets 150, creatinine of 2.8.
BRIEF HOSPITAL COURSE: Patient is admitted to the Intensive
Care Unit in the context of hypotension, metabolic acidosis.
This was believed to be due to an overwhelming infection and
he was volume resuscitated. However, continuing volume
resuscitation, probably led to worsening of his congestive
heart failure. His creatinine continued to rise leading to a
value of 3.0.
He was eventually extubated, and was able to maintain decent
oxygenation. On the night of [**9-11**], the patient developed
new episodes of hypotension. At the same time, his sputum
was growing Staphylococcus aureus. He was on broad-spectrum
antibiotics throughout hospital stay including Vancomycin,
ceftazidime, levofloxacin, and Flagyl. Patient initially
responded to dopamine, but as the day progressed and
particularly [**9-12**], he had continuous episodes of hypotension
not responding to IV fluids. He was started on dopamine as
well as norepinephrine with very minimal effect.
At this point, he suffered an asystolic arrest, and despite
resuscitative efforts, he expired around 10 a.m. on [**9-12**].
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2197-9-12**] 13:43
T: [**2197-9-13**] 09:13
JOB#: [**Job Number 50889**]
ICD9 Codes: 2765, 4240, 4280, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4588
} | Medical Text: Admission Date: [**2146-3-30**] Discharge Date: [**2146-4-1**]
Date of Birth: [**2066-6-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zestril
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Mechanical ventilation
Central line placement
History of Present Illness:
This is a 79-year-old woman with a pmhx. significant for
dementia, type DM2 (on insulin), PVD s/p bilateral amputation,
HTN, DLP, and CAD who is transferred from medical floor to ICU
for hypoxemic respiratory failure. Ms. [**Known lastname 8738**] was initially
admitted to [**Hospital1 18**] for 3 days of cough, shortness of breath, and
increased work of breathing. According to nightfloat admission
note (patient unable to give history), patient complained of
non-productive cough, shortness of breath (at rest), and sore
throat for the last few days. She also has had chest
discomfort, worsened by both inspiration and cough,
non-radiating, as well as discomfort in her upper abdomen,
phantom leg-pain, and reflux. She's unable to say how long the
chest pain lasted for when it came on. She had one episode of
watery diarrhea. She has not been on antibiotics recently and
had had no changes in medications. Her grandson who she is
around frequently was sick with a cold a few days ago. Her son
also thinks that she is more tired than usual. Her son has not
noticeed a fever.
.
In the ED, VS were: T 96.6, HR 85, BP 130/83, RR 16. She
triggered on arrival w/ O2 sat of 85% on RA, that improved to
high 90s on 2L nc. On exam pt found to have R sided crackles and
wheeze. In the ED BP ranged 160s-200s/70s-100s. Pt received
flagyl, levoquin, and combivent, IVF. ECG w/ sinus tachy 103
bpm, std in v3-v5. Overnight on the floor, she had low O2 sats
that responded to oxygen. On the morning of ICU transfer,
patient had HRs in the 140s with ST depressions V4-V6, 2 sets
0.02 from < 0.01. Patient was going to go for CTA but IV was
infiltrated. On transfer to the ICU vitals were HR: 100, BP:
139/109, RR 30, SP02: 99% on 100% facemask.
Past Medical History:
CAD s/p PCI to OM, w/ 3 vessel disease on cath in [**2140**]
Moderate to severe TR
Systolic and Diastolic CHF (EF 45-50%) per echo in [**2140**]
Pulm HTN
Left cataract surgery in [**2135-11-9**]
PVD s/p fem-peroneal, failed graft underwent left BKA
UTI with sepsis ([**2142**]), recurrent UTIs on suppressive
antibiotics
HTN
Hyperlipidemia
DM2
Positive PPD in [**2132**]
Anemia
CVA in [**2115**], s/p L carotid endarterectomy
Diabetic retinopathy, status post laser therapy x2
Social History:
Patient lives w/ son. At baseline she is A&Ox2-3 (self/place,
difficulty w/ year). She uses a wheelchair. She needs assistance
w/ transferring to wheelchair and ADLs. No history of cigarette
use. Denies ETOH/illicits.
Family History:
Non-contributory.
Physical Exam:
VS: 98.8 155/50 65 26 92/2L
GENERAL: Well-appearing man in NAD, speaking full sentences
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
LUNGS: +Wheeze anteriorly, poor respiratory effort, resp
unlabored.
HEART: Tachy, no MRG, nl S1-S2.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: Bl amputations
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox2
Pertinent Results:
Labs on Admission:
[**2146-3-30**] 09:54PM BLOOD WBC-9.7# RBC-3.69* Hgb-11.2* Hct-33.1*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.4 Plt Ct-244
[**2146-3-30**] 09:54PM BLOOD Neuts-81.4* Lymphs-11.2* Monos-4.3
Eos-2.6 Baso-0.4
[**2146-3-30**] 09:54PM BLOOD Glucose-174* UreaN-13 Creat-0.8 Na-132*
K-3.6 Cl-96 HCO3-26 AnGap-14
[**2146-3-30**] 09:54PM BLOOD cTropnT-<0.01
[**2146-3-30**] 09:54PM BLOOD Lactate-1.4
.
Studies:
[**2146-3-30**] CXR:
IMPRESSION: Markedly limited study. If clinically feasible,
consider PA and lateral views in the radiology suite for more
sensitive evaluation.
.
ECHO [**2146-4-1**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %) secondary to
inferior posterior hypokinesis. The right ventricular cavity is
dilated with depressed free wall contractility. There are focal
calcifications in the aortic arch. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CXR [**2146-4-1**]:
FINDINGS: In comparison with the study of [**3-31**], there is little
change in the appearance of the monitoring and support devices.
Enlargement of the cardiac silhouette is again seen with
evidence of pulmonary edema, though the vascular congestion is
less than on the prior study. Again, the possibility of
superimposed pneumonia would be difficult to exclude in the
appropriate clinical setting.
Brief Hospital Course:
This is a 79-year-old woman with a pmhx. of DM II, COPD, HTN,
hyperlipidemia, PVD, and CHF who is admitted with fever and
respiratory distress.
.
# HYPOXEMIC RESPIRATORY FAILRUE: Patient with an elevated a-a
gradient, respiratory distress, and fever, raising concern for
pneumonia. Sputum with gram positive cocci. Ms. [**Known lastname 8738**] was
treated broadly with antibiotics and anti-virals. However, she
continued to decline clinically, with increased O2 requirement
and eventual need for intubation. Her blood pressures decreased
as well, and although she was initially volume responsive,
pressors were eventually started to maintain adequate perfusion.
On [**4-1**], as patient's clinical status continued to worsen,
family decided to withdraw care. Patient was terminally
extubated and pressors were stopped. With her family at the
bedside, Ms. [**Known lastname 8738**] passed away peacefully on [**4-1**] at 10:25pm.
Family declined an autopsy.
.
# CHEST PAIN: Ms. [**Known lastname 8738**] had a bump in troponins upon arrival
in the MICU. This was felt to be likely from demand ischemia in
the setting of severe respiratory distress however, acute
coronary syndrome could not be ruled out. Patient was not a
candidate for catherization, and she was started on a heparin
drip. She was continued on beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **], and statin.
Medications on Admission:
ATORVASTATIN [[**First Name3 (LF) **]] 20 mg daily
CITALOPRAM 20 mg once a day
CLOPIDOGREL [PLAVIX] 75 mg Tablet daily
IMIPRAMINE HCL 25 mg QHS
INSULIN GLARGINE [LANTUS] 20 units qam
ISOSORBIDE MONONITRATE [IMDUR] 30 mg Tablet Sustained Release
once a day
LACTULOSE 15 CC po daily
METFORMIN 850 mg twice a day
METOPROLOL TARTRATE [LOPRESSOR] 150mg po daily
MIRTAZAPINE [REMERON] 30 mg at bedtime
NITROFURANTOIN (MACROCRYST25%) [MACROBID] 100 mg once a day
ROSIGLITAZONE [AVANDIA] 4 mg once a day
VALSARTAN [DIOVAN] 160 mg Tablet once a
day
ASPIRIN 325 mg once a day
CYANOCOBALAMIN 250 mcg once a day
MAGNESIUM OXIDE 400 mg once a day
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
ICD9 Codes: 0389, 5849, 4019, 4280, 4168, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4589
} | Medical Text: Admission Date: [**2131-3-26**] Discharge Date: [**2131-3-29**]
Date of Birth: [**2079-11-1**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Levaquin / [**Location (un) **] Juice
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypoglycemic episode, cough
Major Surgical or Invasive Procedure:
.
History of Present Illness:
Mr. [**Known lastname 7264**] is a 51-year-old male with past medical history
significant for type I diabetes and mental retardation who was
brought to ED from his group home after an episode of
hypoglycemia with FSG of 37 and repeat FSG of 40 even after
having his dinner. EMS was called and he was given [**12-16**] amp of
dextrose enroute to [**Hospital1 18**]. Per caregivers, patient's mental
status was at usual baseline. In the ED, initial vs were: T [**Age over 90 **]F,
P 86, BP 104/63, RR 20, O2 saturation rate is 97% room air.
Glucose trend in ED included 0030: fs=[**Telephone/Fax (1) 7265**]: fs=[**Telephone/Fax (1) 7266**]:
fs=173.
He also had a fever to 103F, noted cough on exam and tachypnea
to mid 30s range. No ABG was done in ED. CXR revealed
infiltrates in LLL and CTA also showed bilateral lower lobe
predominant opacities with more confluent consolidation in the
LLL. No evidence of pulmonary embolism.
He was given 1L NS IVFs, 1g IV Ceftriaxone, 500mg IV
Azithromycin, and 1g Vancomycin for broad coverage for PNA.
.
On arrival to the ICU he appeared to be in no apparent distress
and was able to answer select yes/no questions but communication
was limited so most of history collected from his group home
care giver. Patient appeared very pale and had very dry mucous
membranes and dry tongue that were quite noticeable.
Past Medical History:
-mental retardation; lives in group home
-Type I diabetes ; HgbA1c 8.7 on [**2131-2-15**]
-recurrent dermatitis
-chronic pancytopenias (since [**2119**])
-hyperlipidemia
-Iron Deficiency Anemia
-history of B12 deficiency
Social History:
Lives in group home. Requires assistance with medications.
Limited prior tobacco use, unable to specify amount.
Family History:
unknown
Physical Exam:
Vitals: T 99.7F, HR 111, BP 128/62, RR 21, O2 saturation 98% on
3L NC
General: alert, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP at 5-6cm, no LAD, no thyromegaly
Lungs: Bibasilar crackles, no wheezes, rhonchi
CVS: 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 in place
NEURO: CNs [**1-26**] in tact, EOMI, sensation to light touch in tact,
toes downgoing, rest of exam limited
SKIN: pale complexion, no bruising, no rashes or lesions
Ext: warm, well perfused, 2+ peripheral pulses x 4 extremities
and no cyanosis or edema
Pertinent Results:
Initial studies:
Micro:
-Blood Cultures x2 pending
-UA negative
.
CXR: lower lobe opacities noted on left side
.
CTA:Techincally limited study, with suboptimal opacification of
segmental and subsegmental vessels. No central or large
segmental PE. Bilateral lower lobe predominant
peribronchovascular opacity with more confluent consolidation in
the LLL, suggestive of bronchopneumonia. Hilar and mediastinal
adenopathy is likely reactive. Aberrant right subclavian artery
.
EKG: sinus tachycardia at 116, no ST elevations/depressions
Brief Hospital Course:
Middle aged Male with history of MR, brittle DM I who presented
with hypoglycemia, multifocal PNA initially admitted to the ICU
for resp distress but transferred to the floor without need for
intubation.
## Multifocal PNA: Pt noted on CXR and Chest CT to have
multifocal PNA. He was initially admitted to the ICU given the
concern for possible intubation [**1-16**] tachypnea however his
breathing rate has subsequently improved. He was transferred
from the ICU to the floor on IV Vancomycin, Cefepime and
Azithromycin. Microbiology work up has consisted of blood
cultures, MRSA screen. Urine legionella was also negative. He
was transitioned to oral antibiotics of Azithromycin however he
was noted to develop a drug rash. It is unclear if it was due to
the Azithromycin versus Zofran, though I suspect it may be
Azithromycin given his history of abx allergies. He was
transitioned to Doxycycline Hyclate 100mg twice a day.
## Thrombocytopenia: Pt was noted to have some thrombocytopenia
during his hospitalization but did not require any platelet
transfusions. On review of OMR it appears he has a history of
thrombocytopenia down to the 60s-100s between [**2119**]-[**2126**]. His
platelet count was trended and noted to improve, transient plt
drop may have been due to Vancomycin, can continue outpatient
follow up.
## Hypoglycemia: Pt noted to be hypoglycemic prior to admission,
though subsequent CBGs showed no hypoglycemia. The hypoglycemia
was likely due to poor PO intake given his infectious state.
[**Last Name (un) **] was consulted and followed the patient in house, he was
discharged on Lantus 20units and Metformin 500mg.
## Mental Retardation/Agitation: He was continued on his home
regimen of Clonazepam.
## Hyperlipidemia: He was continued on Simvastatin 40mg qHS
Medications on Admission:
--Clonazepam 2 mg TID
--Aspirin 81 mg daily
--Cyanocobalamin 100 mcg daily
--Perphenazine 8 mg TID
--Depakote 250 mg Delayed Release once a day
--Fluticasone 50 mcg two sprays nasal daily
--Cholecalciferol (Vitamin D3) 400 units daily
--Calcium Carbonate 500 mg TID
--Simvastatin 40 mg daily
--Senna 8.6 mg x2 HS
--Docusate Sodium 100 mg [**Hospital1 **]
--Tylenol 650mg q4hrs prn
--Lantus 25 units qam
--Insulin Aspart/Novolog sliding scale TID
--Multivitamin daily
--Benztropine 1 mg twice day
--Metformin 500mg [**Hospital1 **]
--Benadryl 25mg q8hrs PRN
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain.
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Benztropine 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*120 ML(s)* Refills:*0*
16. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
18. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: per your insulin sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Multifocal Pneumonia
2. Hypoglycemia
3. Diabetes Mellitus Type I
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 after you were noted to have a
low blood sugar level and a cough. Whilst you were in the
Emergency Room you appeared to have trouble breathing so you
were sent to the intensive care unit. After being observed
overnight with your breathing improving you were transferred to
the regular floor. Prior to your discharge you were noted to
have a rash to one of your medications. We think it was one of
the antibiotics (Azithromycin). Your antibiotics were changed,
after taking this medication you displayed no signs of a rash.
You were started you on two NEW medications:
1. Please take Doxycycline Hyclate 100mg twice a day for the
next 7 days (your last dose of this medication will be [**2131-4-5**])
2.
We CHANGED one of your old medications:
1. Please take 20units of Lantus (also known as Glargine) once a
day instead of 25 units
During your CAT scan of your chest you were noted to have some
lymph nodes in your chest. This is probably due to the infection
you. You will however need to get a CAT scan of your chest in 1
months time. Please have Dr. [**First Name (STitle) **] your doctor make this
appointment for you so he can follow up on this.
You also noted some pain in your arm, it did not appear to be
broken, you can Tylenol 650mg every 4 hours as needed for the
pain.
Followup Instructions:
During your CAT scan of your chest you were noted to have some
lymph nodes in your chest. This is probably due to the infection
you. You will however need to get a CAT scan of your chest in 1
months time. Please have Dr. [**First Name (STitle) **] your doctor make this
appointment for you so he can follow up on this.
Please make sure you follow up with all of your appointments:
Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**2131-4-10**] 10:30am
Name: [**Last Name (LF) 4322**],[**First Name3 (LF) 1569**] L.
Location: [**Hospital 4323**] MEDICAL
Address: [**Location (un) 4324**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 4326**]
Appointment: [**2131-4-9**] 3:30pm
ICD9 Codes: 486, 2875, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4590
} | Medical Text: Admission Date: [**2180-11-11**] Discharge Date: [**2180-11-17**]
Date of Birth: [**2117-10-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
Paracentesis
Liver biopsy
History of Present Illness:
63 year old male with past medical history of alcoholic
cirrhosis complicated by ascites and variceal bleeding, duodenal
ulcer, pancreatic mass, hepatic metastases, CAD, afib on
coumadin who started his clinical decompesation in [**2180-3-26**] with
inguinal hernia. He presented in [**2180-7-27**] with lower
extremity edema and ascites which was attributed to his liver
failure vs chronic systolic heart failure.
.
He had screening EGD done on [**2180-11-7**] which showed nonbleeding
esophageal varices. He presented to [**Hospital **] clinic on [**2180-11-8**]
where he had MRCP that showed cirrhosis, splenomegaly,
pancreatic mass and hepatic metastases. A plan was formed to
further evaluate this condition. Labs were drawn and were most
notable for a HCT of 41, Ca19-9 of 461.
.
He had large volume paracentesis of 8L done on [**2180-11-10**]. He
presented to OSH this morning after having episode of
hematemesis and BRBPR. He was noted to have SBP of 77, HCT 20
and INR 2.3 (of note has been off coumadin for past 10 days).
His BUN/CR was 50/1.3. He was given 3 units of PrBC with bump
in his HCT to 27. He continued to be hypotensive requiring
norepi gtt. He underwent endoscopy which showed gastric varices
vs GEJ varix with clot in upper stomach which could be
dislodged. He was continued on octreotide and protonix gtt and
transferred to [**Hospital1 18**].
.
On arrival to the MICU, he reports feeling better. GI scoped him
as he continued to have BRBPR x 3 with increase in levo gtt.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
cirrhosis decompensated with ascites and variceal bleed
pancreatic mass with metastases and elevated Ca19-9
diverticulitis with a colovesical fistula, which closed
spontaneously.
CAD
Duodenal ulcer
afib, on coumadin (not for last ten days)
history of CHF
Social History:
No Alcohol, Tobacco or drugs
Family History:
Not contributory to current presentation
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: non-tender, distended but soft, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
Pertinent Results:
MICU Labs:
[**2180-11-14**] 04:03AM BLOOD WBC-8.7 RBC-3.63* Hgb-11.5* Hct-34.3*
MCV-95 MCH-31.6 MCHC-33.4 RDW-20.2* Plt Ct-131*
[**2180-11-13**] 03:55AM BLOOD WBC-12.0* RBC-3.74* Hgb-11.7* Hct-34.4*
MCV-92 MCH-31.2 MCHC-33.9 RDW-19.7* Plt Ct-149*
[**2180-11-12**] 04:52AM BLOOD WBC-17.8* RBC-3.47* Hgb-10.9* Hct-32.7*
MCV-94 MCH-31.5 MCHC-33.4 RDW-19.3* Plt Ct-237
[**2180-11-11**] 11:29PM BLOOD WBC-14.6*# RBC-3.02* Hgb-10.0*#
Hct-29.2*# MCV-97# MCH-33.0* MCHC-34.1 RDW-18.6* Plt Ct-217
[**2180-11-14**] 04:03AM BLOOD PT-16.1* PTT-36.4 INR(PT)-1.5*
[**2180-11-12**] 06:14PM BLOOD PT-15.8* INR(PT)-1.5*
[**2180-11-12**] 12:47PM BLOOD PT-16.6* PTT-31.1 INR(PT)-1.6*
[**2180-11-11**] 11:29PM BLOOD PT-19.3* INR(PT)-1.8*
[**2180-11-14**] 04:03AM BLOOD Glucose-106* UreaN-29* Creat-0.9 Na-144
K-3.8 Cl-119* HCO3-20* AnGap-9
[**2180-11-13**] 03:55AM BLOOD Glucose-128* UreaN-39* Creat-0.9 Na-149*
K-3.2* Cl-119* HCO3-24 AnGap-9
[**2180-11-12**] 05:05PM BLOOD Glucose-139* UreaN-48* Creat-0.9 Na-146*
K-3.3 Cl-116* HCO3-25 AnGap-8
[**2180-11-12**] 04:52AM BLOOD Glucose-134* UreaN-59* Creat-1.0 Na-144
K-4.5 Cl-115* HCO3-21* AnGap-13
[**2180-11-11**] 11:29PM BLOOD Glucose-139* UreaN-61* Creat-1.2 Na-142
K-4.1 Cl-110* HCO3-26 AnGap-10
[**2180-11-14**] 04:03AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.9
[**2180-11-13**] 08:14PM BLOOD Calcium-8.4 Phos-2.3* Mg-2.1
[**2180-11-13**] 03:55AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2180-11-12**] 05:05PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
# CT abd/pelvis
1. No evidence of an actively extravasating GI bleed.
2. Pancreatic tail lesion with multiple hepatic lesions,
concerning for a
primary pancreatic malignancy, possibly a neuroendocrine tumor,
with hepatic
metastases. No evidence of portal or splenic vein thrombosis.
The tumor
appears well defined and peripherally enhancing which is
uncommonly seen in pancreatic ductal adenocarcinoma.
3. Cirrhotic liver and large amount of simple ascites; at the
time of this
study, a diagnostic paracentesis has been already performed.
4. Sigmoid diverticulosis.
# Tagged RBC scan
No evidence of active GI bleeding during 90 minutes of imaging.
RUQ US IMPRESSION: Multiple hepatic lesions which are visualized
on ultrasound and are amenable for ultrasound-guided liver
biopsy. Findings were discussed with referring physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2180-11-14**] with nurse practitioner, [**Doctor Last Name 636**]
Ghanem, and an ultrasound-guided liver biopsy has been scheduled
for [**2180-11-15**].
Hepatic biopsy Path:
1. Adenocarcinoma, moderately to poorly differentiated,
morphologically suggestive of a pancreaticobiliary primary; see
note.
2. Scant adjacent non-neoplastic hepatic parenchyma with
advanced fibrosis and rare nodule formation (confirmed by
trichrome stain), moderate cholestasis and rare associated
neutrophils; see note.
3. Iron stain is negative for significant iron deposition.
Paracentesis:
[**2180-11-15**] 03:54PM ASCITES WBC-190* RBC-225* Polys-6* Lymphs-55*
Monos-0 Mesothe-4* Macroph-35*
[**2180-11-15**] 03:54PM ASCITES Glucose-107 LD(LDH)-45 Albumin-<1.0
Negative for malignant cells
Discharge Labs:
***
Brief Hospital Course:
63 with decompensated cirrhosis and metastatic cancer presents
with episode of hematemesis and BRBPR.
# GIB: The patient initially went to OSH for hematemesis and
BRBPR. The patient was hypotensive and required phenylepherine
while in the unit. An EGD was done in the MICU and no active
source of bleeding was noted. There were grade 1 varices found
in the lower third of esophagus, which were not bleeding, and
with no stigmata of recent bleed. A Dileufoy's lesion was seen
in the stomach that was also not actively bleeding, but 2 clips
were still successfully placed. Both CTA and tagged RBC scan
were negative for any bleeding source, Colonoscopy showed
external hemorrhoids, and portal enteropathy, non bleeding AVMs.
The patient was treated with Protonix [**Hospital1 **] and ceftriaxone for
SBP ppx. In total, he was transfused 7U PRBC, 2 FFP, and one
unit platelets. Patient was transferred to hepatorenal service
with improved hemodynamics and with stable crit, he had no
further GIBs.
# Cirrhosis - Presumably alcoholic. Radiography and SAAG were
consistent with cirrhosis and portal hypertension. Patient had
paracentesis which removed 15L of fluid, was negative for SBP so
Ceftriaxone reduce from 2mg to 1mg daily for ppx against GNR
sepsis in setting of GIB. Hepatic biopsy was performed which
showed adenocarcinoma. Patient was seen by palliative care
services and will go home with VNA and plan for outpatient home
hospice care in the near future. He will see outpatient
Palliative care with Atrius.
.
# Atrial Fibrillation: The patient was on beta blockers and
digoxin for rate his atrial fibrillation; both were held while
in the unit. The patient's coumadin was also held in context of
his bleeding. Only Digoxin restarted on medicine floor.
.
# CAD: While in the unit, the patient's aspirin, beta blocker
were held in setting of GI bleed. Simvastatin and fenofibrate
also held.
.
# Pancreatic mass with liver mets: Unclear etiology, Hepatic
biopsy performed which showed adenocarcinoma consistent with
pancreatic metastasis. A family meeting was held to discuss
these results and to inform the patient of the grim prognosis.
Given his rapidly accumulating ascites and pancreatis metastasis
his prognosis is poor and he is beginning to transition to
palliative care.
# Glaucoma complicated by retinal detachment: The patient was
continued on his home prednisolone and atropine eye drops.
TRANSITIONAL ISSUES:
- Patient going home with VNA services and plan to transition to
home hospice care
- Patient discharged without long term mortality medications to
limit his medication intake and to improve quality of life. Only
medications discharged with included medications to keep him
without symptoms.
- Patient requires twice weekly paracentesis for comfort
Medications on Admission:
ALLOPURINOL 200 mg daily
ATENOLOL 50 mg Tablet daily
ATROPINE 1% drops to left eye once a day
DIGOXIN 250 mcg daily
FENOFIBRATE 200 mg po qdaily
Potassium chloride 20 meq po qdaily
FUROSEMIDE 40 mg daily
PREDNISOLONE 1% right eye three times a day
SIMVASTATIN 40 mg daily
WARFARIN 2.5 mg po qdaily (not taken in past 10 day)
ASPIRIN 81 mg daily
MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM]
Fluticasone inhalation 1 puff [**Hospital1 **] sometimes
Discharge Medications:
1. atropine 1 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
4. pantoprazole 40 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:*0*
5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for itching.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
GI Bleed
End Stage Liver Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasire treatomg ypi diromg this hospitalization. You
were admitted to [**Hospital3 **] [**Hospital **] Medical center after you
had a significant GI bleed which required you to be in the MICU
and receive many units of blood products. After you were
stabilized you were admitted to the medicine service for further
management. You had a paracentesis which removed 13L of fluid so
that a liver biopsy could be completed. Biopsy showed
adenocarcinoma which was most likely from your pancreas. Your
post-procedure course was uncomplicated and you had no further
bleeds.
The following changes to your medicatoins were made:
- START Ursodiol Three times per day
- START Hydroxyzine every 6 hours as needed for itchiness
- STOP Coumadin
- STOP Atenolol
- STOP Aspirin
- STOP Statin
- STOP Fibrate
- CONTINUE Digoxin
Followup Instructions:
You have a follow up appointment with your [**University/College **] Vangard
Heme/Onc physician
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
ICD9 Codes: 4280, 4589, 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4591
} | Medical Text: Admission Date: [**2139-4-5**] Discharge Date: [**2139-4-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 21073**]
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
Endotracheal intubation
EGD
Blood transfusion
History of Present Illness:
86F with stage IV ovarian cancer, prior malignant effusions,
asthma, GERD off prilosec for past few days presenting with
epigastric/mid chest pain, constant since last night, no
radiation. She has not had much to eat over the past few weeks
but had a hot dog on Friday night. Says she has chronic
shortness of breath which has not changed recently. She recently
switched back to carboplatin therapy (1st recent dose [**2139-3-23**])
after going through one cycle of gemcitabine therapy. While she
was on gemcitabine, she experienced significant fatigue,
decreased appetite, early satiety, and weight loss, as well as
increased dyspnea that required a therapeutic thoracentesis on
[**2139-3-17**]. No cough, fevers.
.
In the ED, her heart rate was reported to be in the 90s,
although it apparently increased to the 130s. There was some
dullness to percussion at the right lung base. EKG was sinus
with no ischemic changes. LFTs and lipase were wnl. CXR showed
stable pleural effusion. Patient was given protonix/gi cocktail
with some improvement of symptoms but still had some chest
discomfort. Given h/o malignancy, a CTA was done which was
negative for PE, stable adenopathy/dilated esophagus with
esophageal wall thickening/air fluid levels/distal air and
?obstruction. Patient was transferred to the MICU for EGD and
concern for possible inability to protect her airway after
sedation.
.
While being prepped for the EGD, after having benzocaine spray
administered to her oropharynx, she suddenly became hypoxic to
the 80s and was noted to have rhonchi throughout all lung
fields. Anesthesia was called to intubate in order to perform
the EGD. The patient and family agreed to intubation for
purposes of the procedure. Prior to intubation she was satting
97-100% on a NRB.
.
In the ICU, the patient underwent EGD which showed partially
digested food boluses in the distal esophagus with esophagitis.
Some was retrieved and the rest was pushed forward into the
stomach. She was extubated and transferred to the floor. On
presentation, she feels well and denies abdominal pain, SOB, or
other pain. Denies h/o dysphagia or odynophagia. No diarrhea or
constipation or dysuria. Uses cane to ambulate long distances
but otherwise no limitations.
Past Medical History:
Stage IV ovarian cancer, diagnosed ~4 years ago, failing
treatment but "not hospice yet" (per call-in sheet)
asthma
hypertension
Social History:
The patient lives alone in [**Location (un) 686**], although she has three
daughters who live nearby.
Family History:
No history of ovarian CA, early onset breast CA, uterine CA,
colon CA
Physical Exam:
VS: 99.0, 108/54, 118, 28, 99% 3L NC
Gen: thin female, NAD, very pleasant, accompanied by daughters
[**Name (NI) 4459**]: [**Name2 (NI) 2994**], MM dry, [**Name (NI) 3899**], left upper teeth missing
Chest: decreased BS at right base and dull to percussion, no
chest wall crepitus
CV: tachycardic, regular, no m/r/g, no JVD
Abd: soft, NT, ND, +BS
Ext: no edema, warm
Neuro: A&Ox3, full strength and sensation throughout
Pertinent Results:
Admission labs:
[**2139-4-5**] 02:20PM BLOOD WBC-4.3 RBC-3.75* Hgb-10.8* Hct-32.2*
MCV-86 MCH-28.7 MCHC-33.5 RDW-16.1* Plt Ct-189#
[**2139-4-5**] 02:20PM BLOOD Neuts-77.6* Lymphs-14.2* Monos-6.8
Eos-0.3 Baso-1.1
[**2139-4-5**] 02:20PM BLOOD PT-11.1 PTT-21.0* INR(PT)-0.9
[**2139-4-6**] 11:45AM BLOOD Ret Aut-0.7*
[**2139-4-5**] 02:20PM BLOOD Glucose-102 UreaN-21* Creat-1.1 Na-142
K-4.3 Cl-103 HCO3-28 AnGap-15
[**2139-4-5**] 02:20PM BLOOD ALT-16 AST-24 CK(CPK)-79 AlkPhos-109
[**2139-4-6**] 02:51AM BLOOD CK(CPK)-112
[**2139-4-5**] 02:20PM BLOOD Lipase-37
[**2139-4-5**] 02:20PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2139-4-6**] 02:51AM BLOOD CK-MB-4 cTropnT-0.05*
[**2139-4-6**] 02:51AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
[**2139-4-5**] 02:20PM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-PND
.
Discharge labs:
[**2139-4-9**] 09:30AM BLOOD WBC-3.8* RBC-3.58* Hgb-10.3* Hct-30.2*
MCV-84 MCH-28.8 MCHC-34.2 RDW-17.2* Plt Ct-43*
[**2139-4-7**] 06:05AM BLOOD Gran Ct-2820
[**2139-4-6**] 11:45AM BLOOD Ret Aut-0.7*
[**2139-4-9**] 09:30AM BLOOD Glucose-105 UreaN-10 Creat-1.0 Na-139
K-3.6 Cl-104 HCO3-24 AnGap-15
[**2139-4-8**] 06:15AM BLOOD proBNP-2373*
[**2139-4-9**] 09:30AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
[**2139-4-7**] 06:05AM BLOOD CA125-599*
.
[**2139-4-9**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY:
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2139-4-5**] CT Chest: Markedly thickened distal esophageal wall with
proximal dilatation. There is distal air suggesting some amount
of patency. There is no evidence of tracheal compression.
.
[**2139-4-5**] CXR: Cardiac and mediastinal contours appear stable.
Pulmonary vascularity remains within normal limits. Again seen
are linear opacities at the right base possibly representing
atelectasis versus scar. Persistent small-to-moderate
right-sided pleural effusion is seen, little changed from prior.
Left-sided granuloma again noted. Impression: Little change
from prior study with persistent small-to-moderate right pleural
effusion.
.
[**2139-4-6**] CXR: Persistent bibasilar infiltrates and right pleural
effusion. Subtle evidence for development of mild pulmonary
vascular congestion.
.
[**2139-4-5**] EGD: Findings -
Esophagus:
1) Lumen: There appeared to be a small Schatzki's ring at the
gastroesophageal junction, but this will need to be reassessed
once the small pieces of food have passed.
2) Contents: Undigested food including unchewed pieces of
hotdog were found in the entire esophagus.
3) Mucosa: Esophagitis with erythema, mucosal edema, and
congestion was seen in the distal esophagus that was most likely
due to the food impaction.
Stomach: Normal stomach.
Duodenum: Not examined.
IMPRESSION:
1) Food in the whole Esophagus
2) Esophagitis
3) Schatzki's ring
4) Otherwise normal EGD to stomach antrum
Brief Hospital Course:
86F w/ stage IV ovarian Ca, asthma, HTN, GERD p/w epigastric
pain.
.
## Foreign body esophagitis: Likely from difficult passage of
incompletely chewed food boluses. Schatzki's ring at discovered
GE junction may have contributed (a biopsy was taken of the
GEJ). Patient admitted to MICU for observation and endoscopy.
She was given local anesthtic for endoscopy and became acutely
hypoxic requiring intubation for procedure (?aspiration).
Endoscopy showed food stuck in the distal esophagus which was
removed. Her pain resolved s/p EGD and she was extuabated the
following morning. S&S eval negative for aspiration. Tolerated
full liquid diet. She was started on a PPI [**Hospital1 **] and will followup
with Dr. [**Last Name (STitle) **] from GI for a repeat endoscopy in 2 weeks once
inflammation improves.
.
## Sinus tachycardia, hypertension: Thought possibly related to
pain and anxiety, and was minimal response to IVFs. In addition,
pneumonitis may have contributed. Notably, per OMR notes, HR
frequently in 120's at clinic. She was started on a metoprolol
with good control of HR and BP.
.
## Hypoxia: Transient hypoxia peri-EGD likely due to aspiration
pneumonitis/PNA and treated with 7 day course levofloxacin and
flagyl. Also with elevated BNP and some evidence of fluid
overload and was given lasix with good effect. The patient was
weaned off supplemental O2 and ambulated with stable SaO2.
.
## Ovarian CA: Stage IV with h/o prior malignant effusions. s/p
first cycle of gemcitabine on [**2139-2-23**] complicated by fatigue,
anorexia, dyspnea (required therapeutic thoracentesis by IR on
[**2139-3-17**]). Given side effects, she has been transitioned to
carboplatin and received her first dose on [**2139-3-23**]. Pancytopenic
from carboplatin therapy but not currently neutropenic, however
could potentially be functionally so. Followed by Heme/Onc
during stay. Transfused 1 unit pRBC as anemia due to
underproduction from chemotherapy. Plan to continue carboplatin
q3weeks as outpatient.
.
## Asthma: Atrovent nebs prn, advair.
.
## FEN: Full liquids x 2 days, then advance as tolerated to
mechanical soft solids
Medications on Admission:
Advair 250/50
Prilosec prn
ASA prn
Albuterol prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily): apply to left leg wound.
Disp:*1 months supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Esophagitis
Anemia
Aspiration pneumonia
Secondary:
Ovarian cancer
Asthma
Hypertension
Discharge Condition:
Good
Discharge Instructions:
You were evaluated for abdominal pain, underwent endoscopy, and
found to have food lodged in your esophagus which was removed.
There was inflammation of the esophagus and you will need a
repeat endoscopy to make sure this inflammation has resolved.
During the procedure, you had trouble breathing and required
intubation and mechanical ventilation overnight. You have an
aspiration pneumonia and are being treated with antibiotics
which you should complete even if you are feeling better.
Please take all medications as prescribed.
New medications: levofloxacin, metronidazole, metoprolol
Changed medications: prilosec
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, abdominal pain, sweating, fevers, chills, bleeding, or
other concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2799**] Date/Time:[**2139-4-15**]
12:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2139-4-15**] 12:00
Please follow up with Dr. [**Last Name (STitle) **] for a repeat upper endoscopy
on Wednesday [**2139-4-15**] at 12:00PM, please come at 11:00 AM to Main
lobby [**Hospital Ward Name 1826**] to check in. You can call for directions or
questions at [**Telephone/Fax (1) 463**]. Do not eat or drink anything after
midnight the day of the procedure.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21074**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-4-20**] 10:00
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-4-20**] 10:00
Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-4-20**]
11:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 21075**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4592
} | Medical Text: Admission Date: [**2142-6-29**] Discharge Date: [**2142-7-4**]
Date of Birth: [**2084-6-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Pollen/Hayfever
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Seizures
Reason for MICU transfer: Intubation for airway protection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57F known history of alcohol abuse and withdrawal seizures
presenting with several suspected seizures and a prolonged
generalized seizure this [**Last Name (un) 44550**].
From neurology note:
Per husband, he noted her to have urinary incontinence followed
by brief twitching of both her hands with eye deviation upwards
around 4:30 AM while in bed. He changed the sheets and then went
back to sleep. There was a second short episode around 8AM of
similar semiology with urinary incontience.
Later in the morning, she was noted to have a similar but more
prolonged episode that also involved urination and rhythmic
movements of all extremities. EMS was called and arrived to the
house with her continued seizing, for which she received 4 mg IV
ativan. Total duration of last episode was at least 15 minutes.
Initial ED vitals were temp of 97.4, 98, 148/99, 100% RA.
Patient was noted to be somnolent and unarousable but was
protecting
her airway, but then began seizing again with clonic movements
of
all extremities. She received 6 mg Ativan which did not stop the
event; she was then intubated for airway protection with 120
succinate and 20mg etomodate and given another 4 mg Ativan which
did stop the clinical seizures. She was also given narcan
0.04mg x1.She was started on propofol for sedation.
Per husband, patient has been drinking more heavily in past 3
weeks, but progressed to double or more of her usual for the
past
3 days where she has essentially been drinking and sleeping
only.
The last known drink was at 11PM last night ([**6-28**]) just before
she
went to bed.
Labs remarkable for an etoh level of 20 and serum benzos
positive. K on ABG was 3.1.
On arrival to the MICU, patient is intubated and sedated.
Past Medical History:
EtOH abuse with withdrawal seizures in past
Hypertension
Depression
Sickle cell
Social History:
Works at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Lives with husband, son and
daughter. Another son murdered about one year ago, anniversary
is
coming up. EtOH abuse for at least 10 years, but is sensitive
and
usually affected with 1-2 beers. No tobacco or illicit drug use
per report.
Family History:
Alcoholism in patient's mother and sister. Daughter
with schizophrenia, father was institutionalized as well.
Physical Exam:
Vitals: T:98.6 BP:166/109 P:93 R:21 O2:100
Admission:
General: Intubated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, able to hear sounds in
tube, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, no dolls eyes, no withdrawl to pain, reflexs 2+
patellar, down going toes bilaterally.
Discharge:
VS: 98.0 90 130/80 15 97 RA
GENERAL: AOx3, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: B/l crackles, improved with coughing. No wheezing
appreciated.
ABDOMEN: soft, nontender, nondistended. no guarding or rebound,
neg HSM. neg [**Doctor Last Name 515**] sign.
EXT: No tremors noted, no edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII intact. gait not assessed.
Pertinent Results:
Admission Labs:
[**2142-6-29**] 09:40AM WBC-4.7 RBC-4.32 HGB-14.2 HCT-40.7 MCV-94
MCH-32.9* MCHC-35.0 RDW-15.3
[**2142-6-29**] 09:40AM ASA-NEG ETHANOL-20* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2142-6-29**] 09:40AM GLUCOSE-115* UREA N-7 CREAT-0.6 SODIUM-146*
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-22 ANION GAP-17
Discharge Labs:
[**2142-7-2**] 05:00AM BLOOD WBC-7.9 RBC-3.88* Hgb-12.8 Hct-37.3
MCV-96 MCH-33.1* MCHC-34.4 RDW-15.3 Plt Ct-265
[**2142-7-4**] 07:50AM BLOOD Glucose-103* UreaN-6 Creat-0.6 Na-138
K-3.3 Cl-102 HCO3-26 AnGap-13
Radiology:
Head CT: IMPRESSION: No intracranial hemorrhage or calvarial
fracture. Pan-sinus
disease.
CXR:IMPRESSION: No significant interval changes or evidence of
pneumonia
EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
diffuse background slowing during wakefulness and brief runs of
frontal
intermittent rhythmic delta activity along with triphasic waves.
These
findings are indicative of mild diffuse cerebral dysfunction,
which is
etiologically nonspecific. There are rare multifocal sharp waves
indicative
of multifocal cortical irritation and propensity towards
multifocal seizures.
There are no electrographic seizures. Compared to the prior
day's recording,
there is no significant change
Brief Hospital Course:
57F known history of alcohol abuse and withdrawal seizures
presenting with several suspected seizures and a prolonged
generalized seizure.
Active Diagnoses
# Alcohol withdrawl seizures: History of alcohol abuse and
previous withdrawal seizures. Non contrast Head CT was
negative. Pt was monitored with continuous bedside EEG
monitoring and followed by Neurology for seizure management. Pt
initially required propofol sedation and intubation for airway
protection. The first attempt at extubation on [**6-30**] resulted in
apnea and agitation. However, a second attempt on [**7-1**] was
successful. Thiamine, folate, MVI on board now. Of note,
Dilantin should be avoided in EtOH withdrawal seizures. Once
extubated, the patient was placed on a CIWA protocol with
diazepam. EEG monitoring was discontinued. On the morning of
[**7-2**], she had no asterixis or tremors, but had been given
diazepam as part of CIWA protocol 3 times in prevous 24 hours.
She spoke of grief over the death of her son as a cause of her
drinking, and a social work consult was requested. The patient
was considered stable enough for transfer to the floor from the
MICU. On arrival to the floor, the patient remained stable. She
did not score on the CIWA and required no diazepam. Her vital
signs remained stable, no AMS, and no tremors.
# Hypokalemia: Pt presented with hypokalemia, likely
nutritional. Repleted throughout admission.
#Throat pain: Following transfer from the MICU, the patient
developed a cough, sore throat, and right sided pleurtic chest
pain. These symtoms were most likely secondary to intubation. A
CXR showed no signs of infiltrate or consolidation and the
patient remained afebrile with no white count. The patient was
never SOB or tachypneic. Pain was improving at discharge.
Chronic Diagnoses
# Hypertension: Patient initially hypertensive on admission, but
this resolved with sedation. On extubation, her home dose of
amlodipine was re-initiated.
# Sinusitus: Unclear if active. Home meds held initially, but
fluticasone was restarted when patient was extubated.
# Reactive airway disease. Stable, restarted albuterol MDI
after extubation for her cough.
Transitional Issues
#Patient to follow up with social work recommendations for
alcohol recovery programs.
# Communication: Patient, husband [**Name (NI) **]: [**Telephone/Fax (1) 100588**]
# [**Name2 (NI) 7092**]: Full code
Medications on Admission:
Information was obtained from OMR
1. Fluticasone Propionate NASAL [**12-25**] SPRY NU DAILY
2. Amlodipine 5 mg PO DAILY
3. Multiple Vitamin, Womens *NF* (multivitamin-Ca-iron-minerals)
1 Oral daily
4. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Rinse mouth after use
5. Naproxen 375 mg PO BID:PRN pain
6. Fexofenadine 60 mg PO BID
7. albuterol sulfate *NF* 90 mcg/actuation Inhalation 4-6 hr
cough/ wheezing
8. FoLIC Acid 1 mg PO DAILY
9. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Rinse mouth after use
3. FoLIC Acid 1 mg PO DAILY
4. albuterol sulfate *NF* 90 mcg/actuation Inhalation 4-6 hr
cough/ wheezing
5. Fexofenadine 60 mg PO BID
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
7. Multiple Vitamin, Womens *NF* (multivitamin-Ca-iron-minerals)
1 Oral daily
8. Fluticasone Propionate NASAL [**12-25**] SPRY NU DAILY
9. Naproxen 375 mg PO BID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4249**],
It was a pleasure taking care of you during your time at [**Hospital1 18**].
You came in due to alcohol withdrawal seizures. We stopped the
seizures and sedated you to prevent additional seizures. It has
now been a week since your last drink and we believe you are
stable. The social workers saw you to discuss resources to stop
drinking.
Please continue all of your home meds following discharge
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2142-7-10**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], 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
ICD9 Codes: 2768, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4593
} | Medical Text: Admission Date: [**2195-7-29**] Discharge Date: [**2195-7-30**]
Date of Birth: [**2137-12-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Insulin overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname **] is a 57 year old woman with a history of
locally advanced pancreatic cancer s/p whipple and XRT c/b
radiation enteritis and biliary strictures s/p PBD, diabetes
mellitus, malnutrition, and pancreatic insufficiency. She
reports waking up this morning and calculating that she needed 6
units of Humalog. She accidentally used her Lantus and her
Lantus syringe and injected "6 units" which in her 100 unit
syringe is actually 60 units of Lantus. She recognized that she
used the wrong insulin and the wrong dose and informed her
partner who called [**Name (NI) **]. The [**Last Name (un) **] physician instructed her
to report to the Emergency Department.
.
In ED VS were T 98.4 HR 100 BP 145/54 RR 18 SpO2 100. Serial
finger sticks in ED were 234, 258, 240, 241. She was given 1 L
NS IV and zofran 4 mg IV prior to transfer to the MICU for
glucose monitoring overnight.
.
On presentation to the ICU she denies any specific complaints.
She admits to a history of depression but denies any intent of
self harm. She denies any history of suicidal or homicidal
ideation.
Past Medical History:
1. locally advanced pancreatic cancer
- s/p Whipple procedure [**9-2**] with positive margins
- s/p cyberknife radiation [**1-4**]
- s/p adjuvant chemotherapy with EB-XRT with chemosensitization
with capecitabine and adjuvant Gemcitabine c/b radiation
enteritis and gastric outlet obstruction due to adhesions, s/p
laparotomy [**12/2193**]
- biliary stricture [**12-30**] radiation s/p biliary drain in setting
of biliary obstruction with biliary tube replacement in
[**4-16**]
2. Malnutrition s/p Nasojeojunal Tube placement [**11-5**]
3. pancreatic insufficiency
4. gallstone pancreatitis [**2189**]
5. depression
6. diabetes mellitus
7. anemia
Social History:
Currently lives with her partner [**Name (NI) **] who is well-informed and
involved in all of her medical care. Used to work as a
self-employed house cleaner. She has a 20-pack-year history of
smoking and quit in [**2194-8-28**]. She used to drink alcohol
occasionally but none since her cancer diagnosis. She denies use
of herbal medications or illicit drugs. She is able to ambulate
short distances without assistance but often is aided by her
partner [**Name (NI) **].
Family History:
Significant for mother with uterine cancer.
Physical Exam:
GA: oriented to day of the week, location, and self not oriented
to date, cachectic, fatigued
HEENT: PERRLA. icteric sclera, dry MM. no LAD. no JVD. neck
supple.
Cards: RRR, 1/6 systolic murmur
Pulm: CTAB no crackles or wheezes
Abd: distended, soft, +BS. no rebound,guarding, dressing on RUQ
c/d/i, biliary drain in place and capped
Extremities: warm, 2+ distal pulses
Skin: mildly icteric, dry,
Neuro/Psych: CNs II-XII intact. Mild asterixis. Conversant,
follows commands. Moves all four extremities
Pertinent Results:
[**2195-7-29**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2195-7-29**] 04:20PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2195-7-29**] 12:00PM GLUCOSE-216* UREA N-36* CREAT-0.8 SODIUM-133
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-16
[**2195-7-29**] 12:00PM ALT(SGPT)-79* AST(SGOT)-109* ALK PHOS-423*
TOT BILI-10.7*
[**2195-7-29**] 12:00PM LIPASE-6
[**2195-7-29**] 12:00PM WBC-10.2 RBC-2.34* HGB-8.5* HCT-25.0*
MCV-107* MCH-36.5* MCHC-34.1 RDW-14.9
[**2195-7-29**] 12:00PM NEUTS-86* BANDS-0 LYMPHS-8* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2195-7-29**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2195-7-29**] 12:00PM PLT SMR-NORMAL PLT COUNT-238
Brief Hospital Course:
57 year old history of locally advanced pancreatic cancer s/p
whipple and XRT c/b radiation enteritis and biliary strictures
s/p PBD, diabetes mellitus, malnutrition, and pancreatic
insufficiency who presents after unintentional insulin overdose.
# Insulin overdose: Patient unintentionally administered 60
units of Lantus instead of the intended 6 units of Humalog due
to picking up the wrong insulin and syringe. She denied any
symptoms of hypoglycemia. She was admitted to the MICU for close
monitoring. Her glucose remained > 200 for nearly 24 hours after
the administration. It is unclear if she truly gave herself this
much insulin.
# Acute on chronic nausea/vomiting: Patient with long standing
nausea/vomiting and early satiety due to xrt enteritis. Patient
reported increase in frequency of bilious vomiting in the last
several days. Vomiting felt to be associated with constipation,
increased tube feed rate and capping of percutaneous biliary
drain. She was placed on a good bowel regimen and her tube feed
rate was not increased. She was placed on several anti-nausea
medications and her medications were all adjusted to be taken
down her post-pyloric NG tube to aide in hopes this would
prevent vomiting her vital medications.
# Abnormal LFTs: Was near baseline during admission. Secondary
to history of biliary strictures.
# Anemia: Patient with chronic anemia with HCT slowing drifting
down. Last admission she received 2 u pRBC to increase HCT to
30. EGD was ultimately performed without evidence of bleeding
lesions. Patient with folate and B12 levels greater than assay
[**2195-6-12**].
# Depression: Patient adamantly denies any suicidal or homicidal
ideation as initial concern given suspected insulin overdose.
Continued home fluoxetine and wellbutrin
# Code: FULL
Medications on Admission:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: One (1)
Tablet PO TID (3 times a day).
2. Ursodiol 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2 times
a day).
3. Prochlorperazine Maleate 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
every eight (8) hours as needed for nausea.
4. Fluoxetine 10 mg Capsule [**Month/Day/Year **]: Three (3) Capsule PO DAILY
(Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Bupropion HCl 150 mg Tablet Sustained Release [**Month/Day/Year **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
7. Clonazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
8. Metoclopramide 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO four times
a day as needed for nausea.
9. Lantus 100 unit/mL Solution [**Month/Day/Year **]: Ten (10) Units Subcutaneous
QAM.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Trazodone 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Morphine 15 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every four (4)
hours as needed for pain.
13. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID
(2 times a day).
14. Ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
15. Humalog sliding scale qid
16. Senna [**Hospital1 **] prn
Discharge Medications:
1. Ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO TID (3 times a day).
3. Prochlorperazine Maleate 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO
every eight (8) hours as needed for nausea.
4. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Bupropion HCl 150 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
6. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day) as needed for nausea.
7. Lantus 100 unit/mL Cartridge [**Hospital1 **]: Ten (10) Subcutaneous once
a day.
8. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
11. Ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
12. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) unit
Subcutaneous four times a day as needed for per sliding scale.
13. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
14. Fluoxetine 20 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) mL PO once a
day.
Disp:*300 mL* Refills:*2*
15. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Unintentional insulin overdose
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You presented to the Emergency Department after accidentally
taking additional insulin. You were admitted to the ICU for
close glucose monitoring overnight. Overnight you had no
symptoms of low glucose and your blood sugars remained above
200.
Since you experiencing nausea and vomiting, we have changed two
of your medications to a form you can place in your nasogastric
tube.
1. Change Prilosec to Prevacid
2. Change Prozac pill form to a liquid form
**we have supplied you with these prescriptions. **
It is important that you keep all of your doctor's appointments.
Followup Instructions:
Please call your follow up with your primary care provider and
your gastroenterologist within two weeks of discharge.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2195-9-2**] 3:30
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4594
} | Medical Text: Admission Date: [**2170-10-16**] Discharge Date: [**2170-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
abdominal pain, shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
84 year old male with type 2 DM, hyperlipidemia, HTN, and anemia
presents abdominal pain and "feeling lousy" since the night
prior to admission. The patient reports that the pain began
yesterday before he went to bed, persisted and worsened until
early this am when he decided to go to the ED. He also reports
some mild SOB. Brought to [**Hospital1 18**] by EMS.
.
In ED, SBPs 100s, satting 96% on NRB. CXR showed pulmonary
edema, bilateral effusions. He was given IV lasix with some
improvement in oxygenation followed by an additional IV lasix,
ntg gtt, heparin gtt and plavix 300mg. Abdominal pain,
shortness of breath resolved and on admission to CCU pt reported
that he felt better than he had in a long time.
.
No prior cardiac history.
Past Medical History:
DM, type 2, diagnosed 40 years ago
Hyperlipidemia
Hypertension
Anemia
PVD, claudication
CRI (baseline 1.8)
b/l carotid bruits (right approx 70% peak 323/52, left 60-69%
peak 172)
Prostate CA
Bladder CA
s/p appendectomy
s/p hernia repair
Social History:
Retired truckdriver. Lives with his girlfriend who helps to
take care of him. Ex-smoker (quit 40 years ago), denies alcohol
use.
Family History:
Non-contributory
Physical Exam:
VS T 99.2, HR 65, BP 161/54, RR 29, O2sat 93% on 4L
Gen: Well appearing male in NAD, alert, awake
HEENT: MMM, EOMI
Neck: +JVD (JVP 14), carotid bruit b/l, L>R
CV: normal s1s2, no m/r/g
Resp: crackles bilaterally midway up lung field.
Abd: obese, soft, NT, ND, +BS
Ext: trace pulses b/l, no edema noted
Pertinent Results:
EKG: NSR, nl axis, 1-2 mm STD V4-V6, STE aVR
.
Cardiac cath:
LCMA: diffuse disease and heavily calcified, 60-70% distally
LAD: hazy ostial lesion with non-laminar flow, likely 60-70%
stenosed. Heavily calcified vessel with prox 40%, mid 40-50%,
supplies single diag.
LCx: mid AV groove 40%, branching OM3/LPL with 50% stenosis
prior to bifurcation, small caliber distal AV groove.
RCA: heavily calcified vessel with dense aortic calcium at its
origin; ostial 80% stenosis with mild pressure dampening;
proximal-mid 50%, mid-distal 70%, distal AV groove 50%
Hemodynamics: CO 6.34, CI 3.47
.
Chest CT: IMPRESSION:
1. Limited evaluation of the pulmonary arteries and aorta
without IV
contrast.
2. Pulmonary edema and bilateral pleural effusions.
3. Cholelithiasis.
4. Focal dilatation of the distal right ureter could represent
reflux.
.
[**2170-10-16**] 03:11PM GLUCOSE-185* UREA N-44* CREAT-1.7* SODIUM-138
POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-13
[**2170-10-16**] 03:11PM ALT(SGPT)-53* AST(SGOT)-23 CK(CPK)-126 ALK
PHOS-107 AMYLASE-63 TOT BILI-0.5
[**2170-10-16**] 03:11PM CK-MB-7 cTropnT-0.58*
[**2170-10-16**] 03:11PM ALBUMIN-2.7*
[**2170-10-16**] 03:11PM %HbA1c-7.1* [Hgb]-DONE [A1c]-DONE
[**2170-10-16**] 03:11PM WBC-9.9 RBC-2.75* HGB-8.8* HCT-25.2* MCV-92
MCH-32.2* MCHC-35.0 RDW-17.4*
[**2170-10-16**] 03:11PM PLT COUNT-239
[**2170-10-16**] 03:11PM PT-13.0 PTT-30.6 INR(PT)-1.1
[**2170-10-16**] 02:40PM TYPE-ART PO2-68* PCO2-34* PH-7.42 TOTAL
CO2-23 BASE XS--1 INTUBATED-NOT INTUBA
[**2170-10-16**] 02:40PM HGB-10.0* calcHCT-30 O2 SAT-92
[**2170-10-16**] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2170-10-16**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-10-16**] 08:00AM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2170-10-16**] 07:54AM LACTATE-1.2
[**2170-10-16**] 07:50AM GLUCOSE-362* UREA N-43* CREAT-1.8* SODIUM-136
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
[**2170-10-16**] 07:50AM CK(CPK)-78
[**2170-10-16**] 07:50AM CK-MB-NotDone cTropnT-0.13*
[**2170-10-16**] 06:45AM cTropnT-0.15*
[**2170-10-16**] 06:45AM CK-MB-NotDone
.
Brief Hospital Course:
Mr. [**Known lastname 32923**] is a 84 year old male with DM2 who presented
with shortness of breath and abdominal pain, found to be
consistent with heart failure exacerbation resulting in demand
ischemia vs. UA/NSTEMI, found to have 3VD on cath.
.
Cardiac
1)Ischemia: Mr. [**Known lastname 32923**] presented with heart failure and ST
elevation of aVR. As his ECG was concerning for severe disease,
he was taken to the cath lab for possible evaluation. He was
found to have 3VD and he was evaluated by CV surgery for
possible CABG. He was taken off of Plavix for possible surgery.
They requested an echocardiogram and carotid ultrasound. He
was found to have right ICA 70-79% stenosis, left ICA 60-69%
stenosis. It was also noted that the patient had aortic
calcifications on CT scan. The above risk factors in addition
to his renal disease and advanced age pushed the decision
towards medical management. Plavix and aspirin were restarted.
.
2) LV function: The patient had a echo done on [**10-17**] which
showed an EF>60%. However, it was felt that the patient's
shortness of breath was likely secondary to pulmonary edema as
he had a PCWP >18. He was diuresed during this admission
(78kg->73kg) and electrolytes were followed. Diuresis resulted
in improved oxygen saturation and he was weaned from 4L NC to 2L
NC. Given appearance on CXR, there was some concern he may have
underlying lung disease. Would consider outpatient PFTs and
chest CT for further evaluation. He was discharged to home with
home O2 and PCP f/u.
.
3) Hypertension: Mr. [**Known lastname 32923**] had persistently high blood
pressures on hospital day [**2-2**]. He was placed on a nitro drip,
started on metoprolol. He was switched back to his outpatient
regimen of labetolol 900mg [**Hospital1 **], valsartan 160mg [**Hospital1 **], and norvasc
10mg QD. The nitro drip was weaned off on HD4 and imdur was
started in its place. Off of the nitro drip his SBPs have been
in the 150-160s which is probably appropriate for him given his
heart disease.
.
4) Renal: The patient's baseline creatinine is 1.8. He was
given a dye load during catheterization and therefore his
creatinine was carefully monitored. He has a slight increase in
creatinine which was felt to be due to diuresis. At discharge,
the patient's creatinine was at baseline.
.
5) Neuro: Mr. [**Known lastname 32923**] was disoriented during the admission,
occassionally unable to name the hospital and the date, likely
due to acute delerium on baseline dementia. His mental status
appeared to improve throughout the day. His delirium was likely
due to the hospitalization. He was closely monitored for signs
of infection and his CXR was clear of infiltrate and UA was
negative.
.
6) Anemia: The patient reports a history of anemia for which he
receives procrit every 3 weeks. He received 2U on this
admission with a less than expected bump in hematocrit. He was
guaiac negative and following hematocrits increased
appropriately.
7) Endocrine: Mr. [**Known lastname 32923**] has type 2 DM, with a HgbA1c of
7.1%. He was placed on a regular insulin sliding scale, with
QACHS finger sticks, but given his daily requirements was also
placed on fixed dose glargine. He was discharge on home insulin
and was instructed to measure fingersticks [**Hospital1 **] prior to his PCP
f/u appointment so that his insulin regimen can be appropriately
adjusted.
8) FEN: The patient was diuresed and therefore electrolytes were
checked frequently. He was repleted as necessary. He was
taking good PO. His B12 level was checked as he was on
supplementation as an outpatient and was found to be within
normal limits. He was continued on supplemental B12 while an
inpatient.
9) PPx: He was given pneumoboots while he was unable to
ambulate.
Medications on Admission:
Avandia 8mg daily
Insulin 2U qam (plus novolog)
Procrit (every 3 weeks)
Cilostazol 100mg [**Hospital1 **]
Lipitor 80mg daily
Diovan 320 daily
Glyburide 15.0 qam
Labetolol 600mg [**Hospital1 **]
Furosemide 40mg daily
ASA 81mg daily
Norvasc 10mg daily
Vitamin B12
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. insulin
insulin sliding scale per attached scale.
9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
Disp:*1 1* Refills:*2*
10. syringe
0.5 cc insulin syringe with 25 guage needle
dispense 100 refill 2
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. oxygen
3.5L O2/min continuous for portability pulse dose system.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale units Subcutaneous prn, per attached sliding scale.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Congestive heart failure
Coronary artery disease
Secondary:
Diabetes mellitus, type 2
Anemia
Renal insufficiency
Discharge Condition:
Stable. The patient is chest pain free, denies shortness of
breath and is ambulating on his own.
Discharge Instructions:
You were admitted for a small heart attack. You underwent
cardiac catheterization and were found to have multivessel
coronary artery disease. After evaluation by the surgeons, it
was decided that medical management of your heart disease would
be the best treatment for you. It is therefore important that
you take all of your medications as prescribed.
You are taking some new medications including a medication
called plavix. Additionally, you are taking a medication called
Imdur which is used to treat high blood pressure and the dose of
your labetolol has been increased to 900mg twice daily, from
600mg twice daily.
The other medications remain the same.
Please keep all outpatient appointments.
If you begin to experience any shortness of breath, chest pain,
lightheadedness or dizziness please call 911 or your physician
[**Name Initial (PRE) 2227**].
.
Please discuss with your PCP about getting pulmonary function
tests as an outpatient.
Followup Instructions:
You need to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] on Thursday
[**10-25**] at 10 am. [**Telephone/Fax (1) 5294**].
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 8937**] in
cardiology on [**10-30**] at 1:00pm.
ICD9 Codes: 4280, 5859, 4019, 2859, 2930, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4595
} | Medical Text: Admission Date: [**2119-7-24**] Discharge Date: [**2119-8-1**]
Date of Birth: [**2056-10-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Shellfish / OxyContin / Codeine
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 20893**] is a 62 y/o female with a history of breast cancer,
lung cancer and tracheal cancer (currently being treated with
chemo and radiation), and hypertension who presented with a 5
day history of nausea, vomiting a poor PO intake. She notes that
after her radiation therapy on Thursday she developed
progressive nausea with vomiting daily. She notes that this is
not her first cylce of radiation and that she typically gets
nauseated after her radiation. Due to persistent nausea and
vomiting she presented to the ED.
.
In the ED inital vitals were, 98.6 82 132/105 16 99% RA. She was
noted to have heart rate in the 180's and after a few doses of
IV diltiazem she was started on a dilt drip. She was
hemodynamically stable during this. She was transferred to the
ICU with a HR in the 130's.
.
Upon arrival to ICU, she noted that she was doing well however
was having significant throat pain. She denied any
lightheadedness or chest pain. She was asking for her pain
medications but was asking for food.
Past Medical History:
- Hypertension
- Asthma
- Breast Cancer [**1-/2103**]
- Depression
- Hyperlipidemia
- Rheumatoid arthritis
- Osteoarthritis
- bilateral carpal tunnel syndrome w/ hand weakness
- spondylolisthesis of L4-5, radiculopathy w/stenosis
- Right total shoulder arthroplasty [**10/2114**]
- Right total knee arthroplasty
- Left shoulder replacement
- Lung cancer s/p lobectomy
- Fibromyalgia
Social History:
Lives by herself, but has a lot of support from her children and
grandchildren. Her husband was in a coma/vegetative state since
a car accident in [**2099**], died one month age 8/[**2118**]. She smokes 4
years +, but denies alcohol or illicit drug use.
Family History:
No brothers and sisters.
Father died of pneumonia.
Mother with breast cancer; died of MI (first MI at age 24)
Daughter with metastatic breast cancer
Physical Exam:
ON ADMISSION:
Vitals:VITALS: Tm 97.7, 159/69, 91, 18, 98-100%RA
PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, scant hair
regrowth
Neck: supple, no JVD, no LAD, radiation burns scattered on chest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate/rhythm, normal S1 + S2
Abdomen: soft, non-tender, mildly distended, bowel sounds (+),
no rebound or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ON DISCHARGE:
VITALS: 97.7-98.2, 144-148/81, 90, 18, 96-100%RA
I/O: 980 + [**Telephone/Fax (1) 97782**] (diarrhea X 1)
PHYSICAL EXAM:
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, scant hair
regrowth
Neck: supple, no JVD, no LAD, radiation burns on chest
Lungs: wheezes bilaterally, decreased BS posteriorly in bases
CV: Regular rate/rhythm, normal S1 + S2
Abdomen: soft, non-tender, distended, bowel sounds (+), no
rebound or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
[**2119-7-24**] 12:15PM BLOOD WBC-1.8* RBC-2.62* Hgb-9.4* Hct-26.9*
MCV-103* MCH-35.9* MCHC-34.9 RDW-14.1 Plt Ct-159
[**2119-7-24**] 12:15PM BLOOD Neuts-86.5* Lymphs-9.8* Monos-3.1 Eos-0.2
Baso-0.4
[**2119-7-24**] 12:15PM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-136
K-4.3 Cl-101 HCO3-18* AnGap-21*
[**2119-7-24**] 12:15PM BLOOD ALT-188* AST-116* AlkPhos-46 TotBili-0.5
[**2119-7-24**] 12:15PM BLOOD Lipase-59
[**2119-7-24**] 12:15PM BLOOD cTropnT-<0.01
[**2119-7-24**] 12:15PM BLOOD Albumin-3.6 Calcium-7.6* Phos-2.9 Mg-1.3*
[**2119-7-24**] 12:15PM BLOOD TSH-0.19*
[**2119-7-25**] 04:02AM BLOOD Free T4-1.3
[**2119-7-24**] 12:26PM BLOOD Lactate-1.9 K-4.0
.
LABS ON DISCHARGE:
[**2119-8-1**] 05:52AM BLOOD WBC-3.2*# RBC-2.57* Hgb-8.8* Hct-25.4*
MCV-99* MCH-34.3* MCHC-34.6 RDW-16.2* Plt Ct-120*
[**2119-8-1**] 05:52AM BLOOD Neuts-70 Bands-3 Lymphs-13* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-3* NRBC-8*
[**2119-8-1**] 05:52AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+
[**2119-7-31**] 06:03AM BLOOD Gran Ct-1290*
[**2119-7-31**] 06:03AM BLOOD Glucose-139* UreaN-25* Creat-0.9 Na-135
K-4.2 Cl-97 HCO3-32 AnGap-10
[**2119-7-31**] 06:03AM BLOOD Calcium-8.9 Phos-2.8# Mg-2.0
.
STUDIES & IMAGING OF INTEREST:
.
CTA [**2119-7-24**]: 1. No PE or acute aortic syndrome.
2. Diffuse full-length circumferential esophageal wall
thickening, likely
indicating esophagitis; however, of unknown etiology.
3. Tracheal abnormality previously noted is no longer present.
The lumen is
patent with no endoluminal lesions noted.
4. Dystrophic calcification in the right breast and fibrotic
changes in the
anterior right lung are stable and presumed related to prior
radiation.
5. Coronary artery disease and cardiomegaly.
6. Ovoid fluid collections around the urethra at the base of the
bladder.
These are stable since at least [**2117-3-19**] and may represent small
urethral
diverticulae. Correlate clinically.
7. Subacute vs. chronic ununited lateral right seventh rib
fracture.
.
ECHO [**2119-7-25**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild global left ventricular
hypokinesis (LVEF = 45 %). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. with
normal free wall contractility. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CTA [**2119-7-29**]: 1. No pulmonary embolism or acute aortic
pathology. 2. Patchy opacities involving both lungs could
reflect edema given the relative rapid onset, but fulminant
pulmonary infection or toxicity from new medication should also
be considered.
Brief Hospital Course:
Ms. [**Known lastname 20893**] is a 62 y/o female with a history of breast cancer,
tracheal cancer and lung cancer (currenlty being treated with
chemo and radiation), and hypertension who presented with a 5
day history of nausea, vomiting a poor PO intake.
.
# Atrial Fibrillation: This appears to be new onset afib for
patient however she is asymptomatic with rapid heart rates. Her
CHADS score is 1 with hypertension. Precipitating factors
include volume depletion, infection and increased pain.
Echocardiography shopwd reduced EF of 45% with mild global
hypokensis consistent with cardiomyocte injury secondary to
hypotension. She was repleted with fluids. Her rate was
initially controlled on diltiazem; following spontaneous
cardioversion to sinus rhythem, she was transitioned first to PO
metoprolol, and then also her home medications lisinopril and
amlodipine. Due to low CHADS would not start coumadin for
anticoagulation, patient also noted to have an aspirin allergy.
.
# Nausea/Vomiting: The most likely etiology includes
chemotherapy and radiation. She notes that her symptoms came on
after her recent dose of radiation. Her nausea was controlled
with PRN ondansetron adn she was given fluids for rehydration;
and her appetite returned and nausea was well controlled.
.
# Metabolic Acidosis: She presented with anion gap metabolic
acidosis. The most likely source of her acidosis includes
ketoacidosis from starvation. Her lactic acid was noted to be
normal therefore less likely. Following fluid resuscitation, her
acidosis resolved.
.
# Tracheal Cancer/ throat pain: She is being treated as an
outpatient with chemo and radiation. She appears to be
tolerating her regimen well. XRT was held on [**2119-7-25**], but she
received XRT on [**2119-7-26**]. In addition she noted significant
throat/ epigastric pain, and had recently been noted to have
oral thrush. She was started on PO fluconazole as well and
nystatin and maalox/diphenhydrane/lidocaine mouthwash to treat a
candidal esophagitis. PEG tube placement was considered to aid
nutrition given the ongoing concern for throat paina nd poor PO
intake.
# Hypertension: Her blood pressure appears to be well controlled
on her current regimen. Due to possible volume depletion, would
introduce medications one at a time.
- continue Metoprolol for rate control
- will introduce lisinopril and amlodipine as BP improves
.
# Chronic Pain: She has chronic pain which is controlled on
narcotics. She was treated intially with IV morphine, and then
transitioned to PO MS Contin and oxycodone once she was able to
resume PO intake.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 solution inhaled every six (6) hours as needed
for asthma
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
puffs q 4 hours as needed for asthma
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
BUDESONIDE - (Not Taking as Prescribed) - 0.5 mg/2 mL
Suspension
for Nebulization - 1 ampule twice a day
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 Tablet(s) by mouth once, may repeat in 1 hour as
needed for headache PLEASE DO NOT TAKE WITH OTHER
TYLENOL-CONTAINING PRODUCTS - No Substitution
CLOTRIMAZOLE - 1 % Cream - apply to affected area twice a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays each nostril
[**Hospital1 **] x 5 days then once a day
FLUTICASONE-SALMETEROL [ADVAIR HFA] - 230 mcg-21 mcg/Actuation
Aerosol - 2 puffs [**Hospital1 **] with spacer
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for swelling
INHALATIONAL SPACING DEVICE [AEROCHAMBER MAX WITH FLOW-VU] -
Spacer - as directed with inhalers twice a day
LEFLUNOMIDE - 20 mg Tablet - 20 mg Tablet(s) by mouth 1 qd
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - [**11-20**]
patches to affected area on for 12 hours, off for 12 hours
LIDOCAINE-HYDROCORTISONE AC [ANAMANTLE HC] - 0.5 %-3 % Cream -
Apply to perianal skin rectally twice daily.
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - apply to portacath 30
min prior to chemo appointment
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
MAALOX:BENADRYL:2%LIDOCAINE MIXTURE - (Prescribed by Other
Provider) - - Take One Tablespoon 15 Minutes before meals and
at bedtime as needed for as needed-[**Month (only) 116**] take an additional dose
each meal
METOPROLOL TARTRATE - 50 mg Tablet - 2 Tablet(s) by mouth three
times a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
MORPHINE - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth
in the morning, 1 tab in the afternoon, and 2 in the evening
NYSTATIN - 100,000 unit/gram Powder - apply to affected area
after bathing once a day
NYSTATIN - 100,000 unit/gram Cream - apply to affected area
twice
a day
NYSTATIN - (Prescribed by Other Provider) - Dosage uncertain
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for nausea
OXYCODONE-ACETAMINOPHEN [ROXICET] - 5 mg-325 mg Tablet - [**11-20**]
Tablet(s) by mouth every 4-6 hours. Not to exceed more than 11
pills in a 24 hour period.
POTASSIUM CHLORIDE - 10 mEq Capsule, Extended Release - 1
Capsule(s) by mouth twice a day as needed for when you take
Lasix
POTASSIUM CHLORIDE [KLOR-CON] - 25 mEq Packet - 1 Packet(s) by
mouth once a day while on lasix
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 2 Tablet(s) by mouth daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
up
to four times per day as needed for nausea
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 2 Tablet(s) by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 inhaled QAM
VARENICLINE [CHANTIX STARTING MONTH PAK] - (Prescribed by Other
Provider) - 0.5 mg (11)-1 mg (3x14) Tablets, Dose Pack - 1
Tablets(s) by mouth Take as directed 0.5 mg ORALLY once daily
for
days 1 through 3, then 0.5 mg twice daily for days 4 through 7,
then 1 mg twice daily. (Not Taking as Prescribed)
.
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg-400
unit Tablet - 1 Tablet(s) by mouth twice a day
CETIRIZINE - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 2
Capsule(s) by mouth once a day pls dispense gel cap
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
four times a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] - Liquid - 1 can(s) by
mouth three times a day diagnosis: persistent anorexia and
weight
loss, recent lung surgery for lung cancer
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
NICOTINE - (Not Taking as Prescribed) - 7 mg/24 hour Patch 24
hr
- apply one patch daily
NICOTINE (POLACRILEX) - (Prescribed by Other Provider) - 2 mg
Lozenge - Take 1 lozenge up to 10 times daily as needed for
urges
to smoke (Not Taking as Prescribed)
NONI [**Doctor Last Name **] LIQUID - (OTC) - - 1 cup once a day
SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth four
times a day
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for asthma.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for swelling.
7. leflunomide 20 mg Tablet Sig: One (1) Tablet PO daily ().
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED) as needed for radiation therapy.
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 2.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*75 Tablet Extended Release 24 hr(s)* Refills:*1*
12. morphine 15 mg Tablet Extended Release Sig: [**11-20**] Tablet
Extended Releases PO twice a day: Take 1 tablet in the morning
and 2 tablets at night.
Disp:*112 Tablet Extended Release(s)* Refills:*0*
13. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every 4-6 hours as needed for pain.
Disp:*560 ML(s)* Refills:*1*
14. prednisone 10 mg Tablet Sig: 1.5 Tablets PO once a day.
15. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
16. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation QAM (once a day (in the morning)).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
19. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for XRT burns.
20. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
22. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
23. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
24. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO QID (4
times a day).
25. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringes* Refills:*2*
26. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*30 syringes* Refills:*0*
27. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: [**11-20**] tbsp Mucous membrane every eight (8) hours as
needed for throat pain.
Disp:*450 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Tracheal Cancer
Atrial Fibrillation
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you were feeling unwell and were found
to have a rapid heart rate. You were initially admitted to ICU
where you were given medication to help slow your heart rate.
You were then transferred to the oncology floor.
.
When you were on the floor, your port appeared malpositioned
which required removal and replacement of your port.
.
You were also started on TPN to help with your nutritional
status and will continue on this until you are instructed to do
so.
.
Lastly you completed your last treatments of radiation while you
were are in the hospital. You will need to follow up with them
as an outpatient.
.
The following changes were made to your medications:
-- STARTED Metoprolol SUCCINATE (Toprol) 100mg, take 2 and half
tablets a day
-- STOPPED Metorolol TARTRATE (Lopressor)
-- STARTED Roxicet 5/325mg, take 5-10mL every 4 to 6 hours as
needed for pain. Do not exceed 40mL per day.
--
Followup Instructions:
Please be sure to keep the following appointments:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2119-8-2**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], 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: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2119-8-3**] at 9:00 AM
With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2119-8-8**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2119-8-5**]
ICD9 Codes: 2762, 4280, 4019, 2724, 3051, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4596
} | Medical Text: Admission Date: [**2160-1-28**] Discharge Date: [**2160-2-2**]
Date of Birth: [**2133-5-22**] Sex: F
Service: [**Company 191**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 26-year-old
female with a complicated past medical history including
vasculitis, GI dysmotility, status post a total colectomy,
multiple intravascular thromboses, and line infections on
chronic TPN, who presented to the Emergency Department with
change in mental status. According to the patient's mother,
she was in her usual state of health until the morning od
[**2160-1-28**] when the family noted decreased mental
status and increased agitation. She was mumbling words and
not making sense. Her mother does think that she did have
some odd behavior the night before. They deny any recent
fevers, chills, nausea, vomiting, headache, sick contacts,
URI symptoms, no change in medications or recent substance
use was elicited in the history. The patient denied recent
falls or head trauma.
On arrival to the ED, she was afebrile and hemodynamically
stable. An infection workup was instituted including blood
cultures, urine culture, head CT, chest x-ray, and LP, none
of which elucidated a potential cause. She was admitted to
the ICU for further management and treatment of electrolyte
abnormalities.
PAST MEDICAL HISTORY:
1. Neuropathic vasculitis incompletely characterized but
extensively worked up; treatments in the past include
steroids, however, those were discontinued several years ago.
2. Gastrointestinal dysmotility syndrome diagnosed in [**2144**],
status post subtotal colectomy in [**2147**] with resultant short
gut syndrome on TPN since [**2148**]. Multiple line thromboses and
difficult intravenous access issues.
3. Central line infections including Staphylococcus
epidermidis, [**Female First Name (un) 564**], and Klebsiella.
4. Poorly characterized pulmonary scarring and infiltrate.
5. Status post cholecystectomy.
6. Anemia of chronic disease.
7. Reflux sympathetic dystrophy with chronic pain.
8. Bladder atony, status post suprapubic catheter placement
in [**2150**].
9. Status post dental extraction.
10. Status post salpingo-oophorectomy of the left.
11. History of VRE in urine.
12. Question of somatization disorder.
13. Status post GJ tube placement for decompression.
14. Status post multiple vascular stents including right IJ,
left brachiocephalic, left iliac and SVC.
15. Chronic pain syndrome.
16. Muscle spasms.
ADMISSION MEDICATIONS:
1. Reglan 10 mg IV q. 12.
2. Famotidine 40 mg IV b.i.d.
3. Lorazepam 3 mg q. three hours p.r.n.
4. Benadryl 100 mg q. three hours p.r.n.
5. Enoxaparin 60 mg subcutaneously b.i.d.
6. Hydromorphone PCA 4 mg per hour with 4 mg bolus q. ten
minutes, lockout of 28.
7. Albuterol p.r.n.
8. Total parenteral nutrition.
SOCIAL HISTORY: The patient lives at home with her family.
She is wheelchair bound. The family and the patient denied
any injection of illicit drug use. No alcohol or tobacco
use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.9, heart rate 100-110, BP 125/80, respiratory rate 16,
saturating 100% on 2 liters nasal cannula. General: The
patient was chronically ill appearing, pale, but comfortable.
HEENT: Anicteric sclerae. Pale conjunctivae. The pupils
were 2 mm and reactive. No nystagmus present. The
oropharynx was clear. The lips were dry. The neck was
supple. JVP, no carotid bruits, no thyromegaly. There is no
lymphadenopathy. The heart revealed a regular rate and
rhythm, normal S1, S2, no murmurs, rubs, or gallops. The
lungs revealed poor effort, clear to auscultation
bilaterally. Decreased breath sounds at the bases. The
abdomen was scaphoid, gastrostomy tube in place, and
suprapubic catheter in place. Bowel sounds soft but present.
Nondistended, nontender. Carotid, radial, femoral, and
dorsalis pedis pulses are equal and intact. Extremities
revealed no rash or edema. Mental status on admission
revealed that the patient was alert and oriented to person
but not place and time, inattentive, unable to assess short
and long-term memory. Grossly full visual fields. Cranial
nerves were intact, II through XII. Motor tone was normal.
Would not cooperate with assessment of strength. However,
moving all four extremities.
LABORATORY/RADIOLOGIC DATA: On admission, white count 2.2,
67 neutrophils, 23 lymphs, 6 monos, 2 eosinophils, crit of
31.7, platelets 138,000. Chem-7 was normal. Calcium,
magnesium, and phosphorus were normal. ALT 15, AST 18, INR
1.3. ESR 75. The tox screen was negative for benzos,
barbiturates, amphetamines, methadone, positive for opiates,
LT acellular, 21 protein, glucose 67. TSH 1.9. ABGs 7.37,
20, 207. Lactate initially 10, repeat 4.
The EKG revealed sinus tachycardia at 157 with normal
intervals, right axis deviation, poor R wave progression,
nonspecific T wave changes.
Chest x-ray showed venous stents in the left subclavian,
right brachiocephalic vein, and superior vena cava, unchanged
in appearance, right Hickman catheter is also apparent,
improvement in previously noted bilateral air space
opacifications. No focal consolidation, effusion,
pneumothorax, or failure.
CT of the head was negative for mass lesions, bleed, or
shift.
HOSPITAL COURSE: 1. MENTAL STATUS: The patient was
admitted to [**Hospital Ward Name 332**] ICU for close monitoring. She was
initially started on broad spectrum antibiotics, Flagyl,
vancomycin, and levofloxacin pending culture workup as it was
thought that her mental status change was due to infection.
Blood cultures, urine culture, U/A, chest x-ray, CSF
examination were all normal and did not point to source of
infection. The patient remained afebrile. The antibiotics
were discontinued. She was noted to have hypomagnesemia and
hypokalemia and these were aggressively repleted. According
to the family, she has had mental status changes in the past
when her electrolytes were abnormal.
Psychiatry consult was obtained and they felt that her
bizarre behaviors were consistent with delirium. There was
also concern that her baseline high doses of narcotics,
benzodiazepines, and anticholinergics could be causing her
confusion. These medications were initially held without
much improvement in her mental status. Further discussion
with the family raised concern that in the past she has done
poorly off these medications and so they were restarted.
Her mental status slowly cleared to near baseline by the
fourth hospital day. She was awake, alert, and oriented
times three, conversant, able to participate in care,
although occasionally using nonsensical speech.
2. FLUIDS, ELECTROLYTES, AND NUTRITION: TPN was initially
held as line infection was being ruled out. Wound cultures
were negative. TPN was restarted on [**2160-1-31**]. Electrolytes
were aggressively repleted as needed.
3. TACHYCARDIA: The patient had intermittent bouts of
tachycardia on the first three hospital days. On hospital
day number four, the patient developed a persistent sinus
tachycardia in the 130s. Initially, this was felt possibly
due to dehydration or pain. Her Dilaudid PCA was titrated
back up to home dose and she was bolused with several liters
of IV fluid. This was not successful in fixing her
tachycardia. PE was considered, however, felt to be unlikely
given the lack of hypoxia or tachypnea. She also continues
to be on Lovenox 60 mg b.i.d. for previous thromboses so it
is already being treated. There is concern for RV strain and
then volume overload. However, at the time of dictation,
tachycardia persists.
Please see addendum for further hospital course and discharge
status.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2160-2-2**] 03:45
T: [**2160-2-2**] 15:54
JOB#: [**Job Number 29422**]
ICD9 Codes: 2930, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4597
} | Medical Text: Admission Date: [**2205-5-13**] Discharge Date: [**2205-5-17**]
Date of Birth: [**2143-8-20**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
diarrhea and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 year old male with a h/o DM1 and ESRD on HD, recent C. Diff
colitis x 2 who finished flagyl approximately 9 days ago and
presented with fevers and increasing diarrhea. Per wife's
report, one day PTA he had a recurrence of diarrhea, similar to
previous episodes of c. diff. He also had a temp to 100.3.
Diarrhea increased on the night prior to admision and he was
febrile to 102 the following morning. Pt thinks he has had more
diarrhea in the past week. Describes ~4 BMs/day, loose,
non-bloody and without mucous. Denies abd pain, N/V or chills.
.
Of note, during last admission,the patient had PNA and pleural
eff with dialysis cath infection. Currently denies SOB, cough,
dysuria, nasal congestion, ST.
.
In the ED VS were T: 101, HR: 110, BP: 171/68 and CBC showed a
left shift. He received tylenol, flagyl and levaquin.
.
Upon arrival to the floor a decision was made to start the
patient on PO vancomycin for presumed c.diff recurrence. Pt has
a h/o anaphylaxis to IV [**Last Name (LF) 22572**], [**First Name3 (LF) **] allergy was contact[**Name (NI) **].
Their recommendation was that the pt receive small doses of
vancomycin with monitoring in the ICU. He received sucessfully
vancomycin PO desensitization.
.
ROS: Per his wife, [**Name (NI) **], when the patient feels extremely ill
he becomes extremely stiff and non-responsive. She also states
he "dissociates" with reality. He has a history of hallucinating
when extremely ill. He also has trouble with his vision when his
blood pressure gets below 150. He has a long standing history of
extremely labile blood pressure. Rest of ROS as above.
Past Medical History:
Past Medical History:
1. DM I for 45 yrs, complicated by triopathy
2. ESRD on HD T/Th/Sa
3. Tunneled cath infections
4. UGIB [**2-16**] PUD
5. VSE septic shoulder
6. Osteomyelitis
7. Left BKA
8. HTN
9. Gastroparesis
10. Depression
11. Right femoral dorsalis pedis graft - [**2198-3-15**]
12. H/o gangrenous cholecystitis
Social History:
Lives in [**Location 701**] with wife [**Name (NI) **] [**Name (NI) 10653**] (Home:
[**Telephone/Fax (1) 22469**], cell: [**Telephone/Fax (1) 22470**]). No EtOH. Former remote
smoker. Used to work in retail 14 yrs ago.
Family History:
Noncontributory.
Physical Exam:
Admission:
VS: Temp: 97.7 BP: 135/61 HR: 107 RR: 15 O2 sat: 97% on 2L Nc
GEN: pleasant, comfortable, NAD, AOx3
HEENT: pupils equal and round, anicteric, MMM, op without
lesions
RESP:decreased sounds at the RLB and dullness to percussion on
that side, rhonchi in LLL that cleared with cough
CV: tachy with reg rhythm, S1 and S2 wnl, 1/6 systolic murmur
loudest LUSB
ABD: normoactive BS, soft, NT, ND
EXT: s/p L BKA. RLE without edema. R foot with out clear
lesions/ulcers, s/p multiple skin grafts to base of foot. 1+ DP
pulse
SKIN: no jaundice
NEURO: AAOx3. Moves all ext spontaneously.
.
Admission:
VS: Temp: 98.4 BP: 144/61 HR: 107 RR: 18 O2 sat: 98% RA
GEN: pleasant, comfortable, NAD, AOx3
HEENT: pupils equal and round, anicteric, MMM, op without
lesions
RESP:decreased sounds at the RLB and dullness to percussion on
that side, rhonchi in LLL that cleared with cough
CV: tachy with reg rhythm, S1 and S2 wnl, 1/6 systolic murmur
loudest LUSB
ABD: normoactive BS, soft, NT, ND
EXT: s/p L BKA. RLE without edema. R foot with out clear
lesions/ulcers, s/p multiple skin grafts to base of foot. 1+ DP
pulse
SKIN: no jaundice
NEURO: AAOx3. Moves all ext spontaneously.
Pertinent Results:
CXR [**5-13**]: There is marked interval worsening of the
right pleural effusion with right fissural fluid noted. Mild
improvement in left pleural effusion is noted. There is
bibasilar atelectasis, worse at the right lung base. Remainder
of the lungs are clear without evidence of vascular congestion.
Moderate kyphotic deformity of the thoracic spine is noted.
Severe degenerative changes in the right shoulder with osseous
demineralization.
.
EKG: sinus tachycardia, low voltages w/TWF in I,II,III, AVR,
AVL, AVF (stable compared to prior). No STE or depressions.
.
Micro:
Stool: C.diff positive
Blood Cx; negative
.
CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass
effect, shift of normally midline structures, or major vascular
territorial infarct is apparent. There is again noted a
prominence of the ventricular system and sulci consistent with
central age-related atrophy, and periventriular white matter
hypodensities idnicating chronic small vessel angiopathy. There
are marked calcifications of the cavernous portions of the
internal carotid arteries and vertebral arteries bilaterally.
There is markedly increased mucosal thickening in the left
maxillary sinus, now filling the sinus almost completely. No
fluid level is seen in the visualized portion. The remainder of
the paranasal sinuses and the right mastoid air cells are clear.
There is new fluid in the mastoid air cells on the left.
IMPRESSION:
1. No evidence of intracranial hemorrhage or mass effect.
2. New fluid in the left mastoid air cells and near-complete
opacification of the left maxillary sinus. Particularly, the
mastoid air cell fluid is concerning for an infectious process
.
CBC
[**2205-5-13**] 08:05AM BLOOD WBC-9.1 RBC-3.82* Hgb-12.4* Hct-37.8*
MCV-99* MCH-32.6* MCHC-32.9 RDW-17.8* Plt Ct-268
[**2205-5-14**] 04:26AM BLOOD WBC-5.0 RBC-3.51* Hgb-11.3* Hct-34.3*
MCV-98 MCH-32.1* MCHC-32.8 RDW-17.1* Plt Ct-208
[**2205-5-15**] 05:03AM BLOOD WBC-5.4 RBC-3.32* Hgb-10.9* Hct-33.2*
MCV-100* MCH-32.9* MCHC-32.9 RDW-17.3* Plt Ct-193
[**2205-5-16**] 07:15AM BLOOD WBC-6.6 RBC-3.57* Hgb-11.4* Hct-35.6*
MCV-100* MCH-31.9 MCHC-32.0 RDW-16.8* Plt Ct-235
[**2205-5-17**] 06:30AM BLOOD WBC-6.1 RBC-3.52* Hgb-11.3* Hct-35.3*
MCV-100* MCH-32.0 MCHC-31.9 RDW-16.3* Plt Ct-263
[**2205-5-13**] 08:05AM BLOOD Neuts-87* Bands-1 Lymphs-5* Monos-5 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
.
Chem 10
[**2205-5-13**] 08:05AM BLOOD Glucose-221* UreaN-24* Creat-5.0* Na-140
K-5.0 Cl-96 HCO3-31 AnGap-18
[**2205-5-14**] 04:26AM BLOOD Glucose-96 UreaN-30* Creat-5.5* Na-142
K-5.5* Cl-100 HCO3-30 AnGap-18
[**2205-5-15**] 05:03AM BLOOD Glucose-144* UreaN-17 Creat-3.9*# Na-140
K-3.3 Cl-100 HCO3-29 AnGap-14
[**2205-5-16**] 07:15AM BLOOD Glucose-95 UreaN-23* Creat-5.3*# Na-143
K-3.7 Cl-103 HCO3-28 AnGap-16
[**2205-5-16**] 10:00PM BLOOD Glucose-300* UreaN-13 Creat-3.2*# Na-144
K-5.0 Cl-108 HCO3-23 AnGap-18
[**2205-5-17**] 06:30AM BLOOD Glucose-162* UreaN-15 Creat-3.7* Na-144
K-4.4 Cl-111* HCO3-25 AnGap-12
[**2205-5-13**] 08:05AM BLOOD ALT-21 AST-32 LD(LDH)-330* AlkPhos-170*
TotBili-0.6
[**2205-5-14**] 04:26AM BLOOD Calcium-9.0 Phos-5.9*# Mg-2.1
[**2205-5-15**] 05:03AM BLOOD Calcium-8.5 Phos-3.9# Mg-1.8
[**2205-5-16**] 07:15AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
[**2205-5-16**] 10:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9
[**2205-5-17**] 06:30AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2
[**2205-5-13**] 10:58PM BLOOD pH-7.46* Comment-PLEURAL FL
[**2205-5-13**] 08:17AM BLOOD Lactate-1.8
Brief Hospital Course:
61 year old male with extensive PMHx who re-presents with
recurrent C. Diff after recently completing a course of Flagyl.
.
# C. difficle colitis: Pt has had several recurrences of c.
diff in the past month (+ toxin assay on [**4-20**] and [**4-12**]) and had
recurrent diarrhea and fevers last night. Pt was initially
started on flagyl. C. diff returned positive. As pt has failed
flagyl before, he was transferred to ICU for monitoring during
po vanc desensitization. He underwent po vanc desensitization
protocol per pharmacy without issues. His diarrhea improved. He
was discharged on a prolonged PO Vanc taper.
.
# Fevers: This is most likely [**2-16**] to c. diff as above. Pt also
recently had a PNA and line infection, both of which are
possibilities. CXR shows increased R pleural effusion, but no
definite infiltrate. Pt underwent thoracentesis on [**5-13**], which
transudative processes, ?[**2-16**] recent pneumonia. Pleural fluid
was sent for culture and did not grow any organism. Pt is HD
dependent and makes no urine. WBC 9.1 but with left shift and pt
currently afebrile. Lacate 1.8 and pressures were stable.
.
.
#ESRD on HD: Patient continued HD on T/Th/Sat schedule.
.
#Type I DM: Per his wife, the patient has very brittle diabetes
with highly variable fingersticks. He was continued on his home
doses of insulin and his NPH sliding scale.
.
#HTN: The patient has extremely labile BP and often goes over
200. The patient has vision changes when blood pressure is below
150. Systolic goal was 150-180. He was continued on labetolol,
minoxidil, lisinopril, and nifedipine at home doses. He had
several episodes of hypertension to SBP 220 which improved with
IV hydralazine. On one occaison, he BP [**Month (only) **] to 150 and the pt had
mental status changes. CT head was negative. His blood pressure
recovered to his normal range SBp 160-180 and his mental status
improved.
.
#Depression: He was continued on sertraline.
.
Medications on Admission:
Home medications (per wife):
Lisinopril 80 mg QHS
Nifedipine 60 mg QHS
Minoxidil 2.5 mg QHS
Labetolol 200 mg [**Hospital1 **] (only if SBP is greater than 150). AM dose
held on dialysis days
Nephrocaps daily
Zoloft 100 mg daily
Benadryl 25 mg daily
NPH 8 units in AM, 4 units in PM
Regular sliding scale
.
Medications on transfer:
Lisinopril 80 mg PO HS
Minoxidil 2.5 mg PO QHS
DiphenhydrAMINE 25 mg PO HS:PRN insomnia
NIFEdipine CR 60 mg PO DAILY
Heparin 5000 UNIT SC TID
Nephrocaps 1 CAP PO DAILY
Insulin SC Sliding Scale & Fixed Dose
Pantoprazole 40 mg PO Q24H
Labetalol 200 mg PO QHS
Sertraline 100 mg PO DAILY
Labetalol 200 mg PO QAM
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)) as needed for only if SBP>150.
4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Benadryl 25 mg Capsule Sig: One (1) Capsule PO once a day.
8. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed below Subcutaneous once a day: 8 unit in am, 4 units
in pm.
10. Vancomycin 125 mg Capsule Sig: as directed taper Capsule PO
Q6H (every 6 hours) for 52 doses: see additional instructions
for taper.
Disp:*52 Capsule(s)* Refills:*0*
11. Vancomycin Taper
week 1: 1 tablet every 6 hours
week 2: 1 tablet every 12 hours
week 3: 1 tablet daily
week 4: 1 tablet every other day
week 5: 1 tablet every 3 days
week 6: 1 tablet every 3 days
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Recurrent C.diff colitis
Discharge Condition:
improved
Discharge Instructions:
You were diagnosed with recurrent clostridium difficile colitis.
You have failed flagyl and therefore underwent successfull oral
Vancomycin densensitization in the ICU. You will to take oral
Vancomycin for 6 weeks on a tapering shedule as follows:
week 1: 1 tablet every 6 hours
week 2: 1 tablet every 12 hours
week 3: 1 tablet daily
week 4: 1 tablet every other day
week 5: 1 tablet every 3 days
week 6: 1 tablet every 3 days
.
If your diarrhea worsens, you have abd pain, fever or chills,
please return to the hospital
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] (PCP)[**Telephone/Fax (1) 22468**] Thursday [**2208-5-22**]:00 am.
Please call to reschedule if this time is inconvient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
ICD9 Codes: 5856, 5119, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4598
} | Medical Text: Admission Date: [**2137-11-15**] Discharge Date: [**2137-11-19**]
Date of Birth: [**2080-6-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Kidney stones, Non ST Elevation Myocardial Infarction
Major Surgical or Invasive Procedure:
1. Percutaneous Nephrostolithotomy
2. Endotracheal Intubation
History of Present Illness:
57 yo F with obesity, HTN, OSA, DM admitted for elective left
kidney stone removal. Regarding her kidney stone, she had a
history of multiple UTIs and left side flank pain. A renal US
demonstrated a 2.4 cm L stone without obstruction. She underwent
PCN without operative complications with EBL 300, receiving 2.5
LR.
.
In the PACU, she was noted to be hypotensive to SBP 90s, and
received 1.5L of fluid and neo 100mcg x3, morphine 10mg and a
propofol drip. s/p extubation, she was bagged for 1hr [**3-14**] to
apnea, requiring reintubation, [**11-16**] admitted to [**Hospital Unit Name 153**] for further
monitoring. Cardiac enzymes were noted to be elevated at trop
0.15 and anti TWI were noted in the EKG and she was started on
aspirin and a betablocker and cardiology consulted.
She was extubated the next day on [**11-16**] without difficulty and on
[**11-17**] the PCN tube was removed. She otherwise has been without
complaints. Denies HA/Blurrivision/N/V/F/C/Abd
pain/Diarrhea/Constipation.
Past Medical History:
- Diabetes
- Hypertension
- Obesity
- OSA
- Hypothyroidism
- Hypertriglyceremia
Social History:
She is a legal secretary. She is a nonsmoker, no alcohol use,
lives with daughter
Family History:
Notable for history of kidney stone in her
brother.
Physical Exam:
97.9 124/62 88 18 94RA
GEN: NAD, obese, [**Last Name (un) 664**]
HEENT: PERRL, EOMI, OP Clear, supple no LAD, JVP obscured
CV: distant HS, rrr no m/r/g
Lungs: CTA b/l no w/r/r
Abd: +BS nt/nd obese, left flank dressing CDI
Ext: no c/c/e
Neuro: aaox3, CNII-CNXII intact no focal deficits
Pertinent Results:
Admission Labs:
[**2137-11-15**] 11:53PM TYPE-ART RATES-15/ TIDAL VOL-600 PEEP-5 O2-50
PO2-180* PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 -ASSIST/CON
INTUBATED-INTUBATED
[**2137-11-15**] 09:18PM GLUCOSE-266* UREA N-26* CREAT-1.2* SODIUM-138
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
[**2137-11-15**] 09:18PM ALBUMIN-3.9 CALCIUM-8.4 MAGNESIUM-1.7
[**2137-11-15**] 09:18PM %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
[**2137-11-15**] 09:18PM WBC-18.4*# RBC-3.85* HGB-10.5* HCT-30.5*
MCV-79* MCH-27.1 MCHC-34.3 RDW-15.6*
[**2137-11-15**] 09:18PM PLT COUNT-387
[**2137-11-15**] 09:18PM PT-12.9 PTT-23.3 INR(PT)-1.1
[**2137-11-15**] 11:35AM PT-12.2 INR(PT)-1.0
.
Discharge Labs:
[**2137-11-19**] WBC 8.0 RBC 4.03* HGB 11.1* HCT 32.7* MCV81* PLT 388
[**2137-11-19**] GLUC 176* BUN 22* CR 1.2* NA 141 K 4.0 CL 101 HCO3 31
.
Micro:
[**2137-11-16**] 8:05 am URINE Source: Catheter.URINE CULTURE
(Final [**2137-11-18**]): GRAM NEGATIVE ROD(S). ~1000/ML.
.
Imaging:
[**2137-11-15**] CXR:
An ETT is present -- the tip lies above the level of the
clavicular heads, approximately 5 cm above the carina and could
be advanced approximately 2 cm.
There is vascular plethora and patchy alveolar opacity
throughout both lungs, most pronounced in the perihilar areas
and left base. While this could relate to alveolar edema and/or
pneumonic consolidation, the appearance is likely accentuated by
low lung volumes in supine positioning. No effusions are
identified.
No supine film evidence of pneumothorax is identified, though
small pneumothoraces may not be readily apparent on a supine
film.
.
[**2137-11-15**] Percutaneous Nephrostomy:
LEFT PERCUTANEOUS NEPHROSTOMY AND URETERAL GUIDEWIRE PLACEMENT
FOR LITHOTRIPSY ACCESS ON [**11-15**]
INDICATION: Large left renal pelvis calculus. Percutaneous
access requested for lithotripsy.
TECHNIQUE AND FINDINGS: Informed consent was obtained and
preprocedure timeout performed. Local 1% Xylocaine anesthesia
and moderate sedation using four divided doses of fentanyl for a
total dosage of 200 mcg and two divided doses of Versed for a
total dosage of 2 mg over one hour.
Using the anatomy of the left renal collecting system as
detailed in a prior CT scan of [**2137-8-16**], and with fluoroscopic
guidance, a 21-gauge needle was advanced from a left
posterolateral approach into a mid-lower pole calix. Antegrade
nephrostogram demonstrated no hydronephrosis of the left renal
collecting system, with contrast tracking around the large stone
in the renal pelvis and down into a nondilated left ureter.
As the needle appeared to have entered a desirable mid-to-lower
pole calix with a direct course to the calculus, the
percutaneous tract was dilated over a guidewire and an 8-French
sheath was introduced and positioned with its tip in the
proximal third of the left ureter. Two Amplatz guidewires were
then passed through the sheath and down into the distal third of
the left ureter. The sheath and external portions of the
guidewires were secured in place.
The patient tolerated the procedure well without immediate
complications and was transferred to the OR for subsequent
lithotripsy.
IMPRESSION: Uneventful creation of percutaneous access, as
detailed above, for subsequent lithotripsy of the large stone in
the left renal pelvis.
.
[**2137-11-19**] Exercise MIBI:
INTERPRETATION:
Imaging Protocol: Gated SPECT
Resting perfusion images were obtained with Tl-201.
Tracer was injected 15 minutes prior to obtaining the resting
images.
Exercise images were obtained with Tc-[**Age over 90 **]m sestamibi.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is adequate.
Left ventricular cavity size is normal (LVEDV = 82 mL).
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 51%.
IMPRESSION:
Normal perfusion study with LVEF = 51%.
.
[**2137-11-19**] Exercise Stress Test:
INTERPRETATION: This 57 year old type 2 IDDM woman was referred
to
the lab for evaluation following a NSTEMI post-operatively on
[**2137-11-15**].
The patient exercised for 8 mintues of a modified [**Doctor First Name **] protocol
and was
stopped for reaching target submax HR. No arm, neck, back or
chest
discomfort was reported by the patient throughout the study. The
baseline inverted T waves normalized with exercise. No
additional ST
segment depressions were observed during exercise or in
recovery. The
rhythm was sinus with no ectopy. Appropriate hemdoynamic
response to
exercise.
IMPRESSION: No anginal type symptoms with non-specific T wave
changes.
Nuclear report sent separately
Brief Hospital Course:
57 YO f h/o DM, HTN s/p percutaenous nephrolithotomy,
complicated by respiratory failure and NSTEMI. Her hospital
course is as follows:
.
NSTEMI: The patient was noted to have elevated troponin of 0.15,
with elevated CK and CK-MB while she was in the [**Hospital Unit Name 153**] post-op for
respiratory management. In the PACU, the patient was noted to
be transiently hypotense and oliguric, likely secondary to
oversedation in the OR. EKG also showed TWI in I, aVL, V2-V6.
The patient was intubated at the time but did not demonstrate
signs or symptoms of an acute cardiac event. Cardiology was
consulted and the patient was started on [**Hospital Unit Name **], metoprolol, and
atorvastatin. Once she was extubated in the [**Hospital Unit Name 153**], the patient
denied any cardiac symptoms. Her cardiac enzymes trended down
thereafter. Heparin was not started. An ACEI was held in the
setting of an elevated creatinine. The patient was transferred
from the ICU to the medical floor for further management. Her
medical therapy was continued without incident. On [**11-19**], the
patient underwent an exercise MIBI (see results above). The
findings were essentially benign, and no need for further
intervention was necessary. On discharge, the patient was on a
beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], statin, and advised to consider starting an
ACEI or restarting her Diovan per her PCP [**Name Initial (PRE) 7219**]. She
was also instructed to adhere to appropriate lifestyle
modifications, and to have her LFTs checked while on the statin.
Her event was thought to be NSTEMI, with possible demand
component given transient hypotension.
.
Respiratory Failure: The patient was intubated for her surgery
without event. However, the anesthesia team was unable to
successfully extubate her in the PACU. Her respiratory failure
was thought due to oversedation with a component of obesity
hypoventilation. She was transferred to the ICU for
observation. She ws extubated without incident with no residual
symptoms. On transfer to the floor and on discharge, the
patient was breathing well on room air without any episode of
shortness of breath.
.
Type 2 Diabetes Mellitus: A recent A1C was 5.5. She was
maintained on her regular outpatient regimen, including insulin
70/30, a sliding scale, and Byetta. Her glucophage was held.
Her sugars remained stable. On discharge, the patient was
advised to continue her insulin and Byetta, and to discuss
restarting her glucophage after consultation with her
PCP/endocrinologist.
.
Kidney Stone: The patient was admitted to the hospital for a
percutaneous nephrostomy with nephrolithotomy. The patient
tolerated the procedure well. She produced good urine output
post-op after a brief period of oliguria. Her urine cleared
over 48-72hrs. Her tube was pulled. The patient was also
started on Ciprofloxacin 500mg PO BID for total 7 day course.
Once the patient was on the floor, her foley was discontinued.
She did not report any pain. Upon discharge, the patient was
instructed to contact Dr.[**Name2 (NI) 825**] office to arrange
appropriate follow-up.
.
Hypertension: Her diovan and HCTZ was stopped in house. She was
begun on metoprolol TID. Her BP remained stable. On discharge,
the patient was given Atenolol, and instructed to consult her
PCP to discuss starting her Diovan/HCTZ.
.
Hyperlipidemia: The patien was started on atorvastatin once
cardiac injury was suspected. A lipid panel was drawn on [**11-19**],
which showed an elevated triglyceride level. She had been on
Tricor as an outpatient which was held in the hospital. The
patient was discharged on atorvastatin, and instructed to not
take her Tricor until proper consultation from her PCP. [**Name10 (NameIs) **]
will need LFTs to monitor on atorvastatin/Tricor.
.
Elevated Creatinine: The patient's creatinine peaked at 1.5
during admission, thought to be due to pre-renal azotemia. Her
creatinine fell once her fluid status improved. Her Diovan was
held. On discharge, her Cr was 1.2. She was instructed to
consult her PCP to discuss starting her Diovan/glucophage.
.
Hypothyroidism: She continued her synthroid without incident.
.
Code: full for this admission
.
Dispo: Pending results of MIBI
Medications on Admission:
Insulin
Diovan
TriCor
Levoxyl
Glucophage
Hydrochlorothiazide
Byetta
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) ML
Subcutaneous [**Hospital1 **] ().
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Non-ST Elevation Myocardial Infarction
2. Nephrolithiasis, percutanous nephrostomy procedure
.
Secondary Diagnoses:
1. Respiratory failure
2. Type 2 Diabetes Mellitus
3. Hypertension
4. Hypothyroidism
5. Hyper-Triglyceremia
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow up appointments. Please return to the hospital with any
chest pain, shortness of breath, trouble urinating, abdominal
pain, or any symptoms that concern you.
.
You were diagnosed with a small heart attack. Given that you
have diabetes, it is likely that you have coronary artery
disease. It is important that you modify any risk factors
including smoking cessation, limiting alcohol use, increasing
your exercise, and eating a healthy diet.
.
We have put you on new medications, including aspirin, a beta
[**Hospital1 7005**] for your heart, and a statin for your cholesterol.
However, your triglycerides were markedly elevated. Please
follow up with your PCP regarding these new medications and to
discuss continuing your Tricor. Please do not take this
medication until discussing with your PCP. [**Name10 (NameIs) **] will need liver
function tests to monitor your statin medication. Your
Diovan/HCTZ has been held. Please discuss restarting these
medications with your PCP.
[**Name10 (NameIs) 357**] follow up with your PCP [**Name Initial (PRE) 176**] 7 days.
.
Please follow up with your [**Last Name (un) **] endocrinologist to discuss
your diabetes treatment. Please continue your insulin and
byetta as before.
.
Please call Dr. [**Last Name (STitle) 770**] of Urology to follow up your kidney
stone removal. Please take Ciprofloxacin for 3 more days.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week to discuss your
recent admission, to address your new medications, to address
starting your Diovan/Hydrochlorothiazide, to check your liver
function tests (LFTs).
.
Please call Dr. [**Last Name (STitle) 770**] tomorrow morning to follow up with
Urology regarding your kidney stone and operation.
.
Please follow up with your endocrinologist as needed
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
ICD9 Codes: 5185, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4599
} | Medical Text: Admission Date: [**2167-10-27**] Discharge Date: [**2167-11-10**]
Date of Birth: [**2101-2-24**] Sex: M
Service: SURGERY
Allergies:
Chromium
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
[**10-27**]:
OPERATION PERFORMED: Open repair of abdominal aortic
aneurysm and bilateral common iliac artery aneurysms with a
Dacron 20 x 10 bifurcated graft as well as a bypass to the
left renal artery.
[**10-29**]:
Operation Performed: Flexible colonoscopy to 60 cm.
History of Present Illness:
This is a 66-year-old gentleman who
has a known large abdominal aortic aneurysm. It has now
grown to 8 cm in size. He has multiple comorbidities;
however, he has been cleared for surgery by cardiology after
cardiac catheterization. He has a suprarenal abdominal aortic
aneurysm which is notamenable to endovascular repair. he has a
single kidney (left) with a stent in the origin which comes off
the aneurysm and will require bypass. In addition, he has
bilateral common iliac artery aneurysms with a very large (5cm)
right common iliac aneurysm which will require extension of the
graft into the iliac bifurcation. Given his risk for rupture,
the patient was consented for an open aneurysm repair
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD RISK FACTORS: DM2, HTN, dyslipidemia, CAD, smoking
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- 50+ pack year history of smoking
- CRI
- RAS s/p L stenting 07, right kidney atretic
- severe COPD
- obesity
- back surgery
- abdominal aneurysm - CT angiogram performed in [**2167-9-20**]
showed the size to be 8 cm. His descending thoracic aort is also
enlarged (less than 5 cm), and the right common iliac artery was
aneurysmal (5 cm) with left common iliac smaller (3 cm)
aneurysm. Of note, the
abdominal aortic aneurysm is pararenal and extends to the left
renal artery (which had been stented in [**2165-2-17**]).
Social History:
The patient in married and lives with his wife. [**Name (NI) **] is retired.
Smokes 1 ppd and has done so for over 50 years. He denies
alcohol or recreational drugs. He does not exercise and has no
dietary restrictions.
Family History:
significant for heart disease. Negative for stroke and diabetes
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Obese, Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2167-11-8**] 04:07AM BLOOD
WBC-9.6 RBC-3.48* Hgb-10.1* Hct-29.3* MCV-84 MCH-29.1 MCHC-34.6
RDW-14.5 Plt Ct-388
[**2167-11-6**] 05:42AM BLOOD
PT-14.5* PTT-26.2 INR(PT)-1.3*
[**2167-11-10**] 06:05AM BLOOD
Glucose-95 UreaN-42* Creat-2.1* Na-139 K-3.3 Cl-101 HCO3-24
AnGap-17
[**2167-11-10**] 06:05AM BLOOD
Calcium-7.9* Phos-3.3 Mg-1.7
[**2167-10-30**] 12:47PM
URINE Hours-RANDOM UreaN-340 Creat-47 Na-89
URINE Hours-RANDOM
URINE Osmolal-380
URINE Uhold-HOLD
RENAL US:
FINDINGS: The right kidney is noted to be atrophic measuring
only 8.0 cm. No vascular flow is identified in the right kidney
and color Doppler imaging.
The left kidney measures 15.2 cm. There is no hydronephrosis. No
cyst or
stone or solid mass is seen in the left kidney.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained from the left kidney only. Note is made that this is a
limited
Doppler study due to the portable technique and the patient's
body habitus. Arterial flow is documented within the left main
renal artery, but cannot be further assessed. Venous flow is
seen in the main renal vein. Resistive indices are mildly
elevated measuring 80, 79, and 73.
IMPRESSION:
1. Arterial and venous flow identified within the left kidney
with mildly
elevated resistive indices in the intraparenchymal arteries. No
further
assessment can be made at the main renal artery due to the
limited nature of this portable technique and the patient's body
habitus.
2. Atrophic right kidney.
Brief Hospital Course:
Mr. [**Known lastname 17353**],[**Known firstname **] was admitted on [**10-27**] with AAA. He agreed to
have an elective surgery. Pre-operatively, he was consented. A
CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other
preparations were made.
It was decided that she would undergo a:
Open repair of abdominal aortic aneurysm and bilateral common
iliac artery aneurysms with a Dacron 20 x 10 bifurcated graft as
well as a bypass to the left renal artery.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
He was transferred to the CVICU for further care. He had a
prolong intubation. [**2167-10-27**] - [**2167-11-5**]. He received mo niter
care and pressure support.
During this time frame pt had ATN. His nephrotoxic drugs were
held. He received PRBC for hypotension and volume support. His
baseline creatinine was 1.6, High 4.6, now 2.1. All his home
meds were restarted. He always maintained good urine output.
Pr also had Bowel movements in the immediate post operative
period. transplant was called. Had mucosal sloughing. His
lactate was normal. This is assumed resolved.
Pt had hypernatremia to 147. This resolved with fluids.
After he was extubated he was then transferred to the VICU for
further recovery. While in the VICU he received monitored care.
When stable he was delined. His diet was advanced. A PT consult
was obtained. When he was stabilized from the acute setting of
post operative care, he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
To note his staples were removed on DC. Steri strips are in
place.
PT HAS RUL OPACITY ON CXR. HE NEEDS TO HAVE THIS WORKED UP. HE
NEEDS A CT SCAN OF CHEST. THIS SHOULD BE DONE BY HIS PCP.
Medications on Admission:
ATENOLOL 25', FUROSEMIDE 20', LISINOPRIL 10', LORAZEPAM 1',
METFORMIN 850", PAROXETINE 20', CRESTOR 20', ASPIRIN 81'
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Metformin 850 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
9. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY
(Daily): please hold for k greater then 4.5.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: prn.
11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Insulin
Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
AAA
Acute Renal failure secondary to blood loss and hypotension
Mucosal sloughing, flex sig
RUL mass, Needs outpt CT scan from PCP
hypotension from blood loss requiring PRBC
Hypernatremia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home or Rehab:
1. It is normal to feel weak and tired, this will last for [**4-27**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2167-11-25**] 2:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2168-7-28**] 4:00
PCP: [**Name10 (NameIs) 17354**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17355**]. You should mnake an appointment
with her ASAP. You need a ct scan of your chest to follow-up on
a lung mass. This was a incidental finding.
Completed by:[**2167-11-10**]
ICD9 Codes: 5845, 5185, 2760, 2851, 5180, 496, 2875, 5859, 3051, 2724, 2768 |
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