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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4600
} | Medical Text: Admission Date: [**2127-10-19**] Discharge Date: [**2127-10-21**]
Date of Birth: [**2065-7-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD with clipping at [**Hospital 27217**] Hospital
History of Present Illness:
62-year old man developed hematemesis and bright red blood per
rectum earlier around 2pm that came on suddenly, accompanied
with nausea, shortness of breath, and feeling severely unwell.
He has a history of partial gastrectomy in [**2115**] for peptic ulcer
disease and reportedly benign tumor where he had presented also
with hematemesis, but no other episodes that he can recall. He
called EMS and was brought to [**Hospital **] Hospital. He had EGD there
that identified a bleeding ulcer that was injected with
epinephrine, clipped, and cauderized. Was on protonix and
octreotide drips. HCT was 41.6, received 2.5L. The patient was
transferred to the [**Hospital1 18**] for further monitoring. If the patient
developed recurrent GIB, then he would need angiographic
intervention which [**Hospital **] Hospital did not have.
Reportedly had fever spike per signout and does have
leukocytosis though the patient denies fever or chills, aches,
or nightsweats; He had taken ibuprofen earlier today for
arthritic pains.
.
In the ED, initial VS: 97.4 75 143/97 16 98
Continued on PPI and octreotide drips. 97.3 67 128/80 10 100% on
2Lnc.
.
Currently, abdomen is non-tender. HCT is drifting downward, but
he is without further episodes of rebleeding.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath other than during acute bleeding episode, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation,
melena, dysuria, hematuria.
Past Medical History:
s/p Billroth II
Social History:
Smokes pipe throughout the day x40 years. Lives at home with his
wife [**Name (NI) 1154**], no children. Retired from stop and shop. Denies
heavy EtOH use, reports only rare use.
Family History:
No bleeding disorders or hereditary cancer syndromes
Physical Exam:
GEN: Thin
HEENT: PERRL, EOMI, MMM
C/V: RRR, normal s1 and s2
PULM: CTAB
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present
EXT: BLE no edema
SKIN: Normal
NEURO: CN 2-12 intact, sensory normal, strength 5/5 in upper and
lower extremities, gait normal
Pertinent Results:
EKG: Sinus at 80 bpm, nl axis, segments and intervals.
CXR: FINDINGS: There is no evidence of infradiaphragmatic air.
Normal size of the cardiac silhouette, normal in appearance of
the lung parenchyma. No
parenchymal opacities, no pleural effusion, no pneumothorax.
On admission:
[**2127-10-19**] 09:55PM GLUCOSE-118* UREA N-29* CREAT-0.8 SODIUM-139
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-24 ANION GAP-12
[**2127-10-19**] 09:55PM WBC-15.4* RBC-4.27* HGB-12.4* HCT-35.8*
MCV-84
[**2127-10-19**] 09:55PM NEUTS-85.2* LYMPHS-11.2* MONOS-2.2 EOS-1.1
BASOS-0.3
[**2127-10-19**] 09:55PM PLT COUNT-311
[**2127-10-19**] 09:55PM PT-13.3 PTT-23.1 INR(PT)-1.1
[**2127-10-19**] 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
On discharge:
[**2127-10-21**] 06:35AM BLOOD WBC-9.2 RBC-3.96* Hgb-11.7* Hct-34.0*
MCV-86 Plt Ct-292
[**2127-10-21**] 06:35AM BLOOD Glucose-116* UreaN-13 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-30 AnGap-10
Brief Hospital Course:
62yo male s/p Bilroth II surgery who presented with sudden onset
BRBPR and hematemesis to [**Hospital1 **], managed endoscopically and
sent here because of concern for repeat bleed or perforation.
Hospital course by problem.
1. Bleeding duodenal ulcer: Patient had an isolated bleeding
ulcer that was managed endoscopically with epinephrine
injection, clipping, and caudery. He had no evidence on
physical exam of viscous perforation and had no free air on an
upright CXR. His hematocrit was stable between 32.7 and 35.9.
He had a leukocytosis to 15.4 on admission that resolved. At
[**Hospital **] Hospital he was initiated on IV octreotide and
pantoprazole; here the octreotide was stopped and the
pantoprazole converted to PO. He was seen by gastroenterology
who recommended keeping him NPO until 24 hours after the
endoscopy and checking his H.Pylori status. He tolerated a full
diet prior to discharge. He is H. Pylori IgG negative.
2. Smoking: Patient smokes a pipe daily at home. He was
counseled to avoid smoking his pipe immediately post procedure
to help with healing, and to cut back on smoking his pipe in the
future for his long-term health.
Medications on Admission:
Takes no medications, prn ibuprofen
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute GI bleed
Duodenal ulcer
Discharge Condition:
Hemodynamically stable, no further bleeding with stable
hematocrit.
Discharge Instructions:
You were admitted because you were vomiting blood and had a
bloody bowel movement. You had a bleeding stomach ulcer that
was closed by endoscopy at [**Hospital 27217**] Hospital. You were
transferred here because they were worried you may have a hole
in your stomach and could become unstable. This does not appear
to be the case. You have been stable since your admission here
and are now ready to go home. You have had no further bleeding
since you've been here.
You were started on the following medication:
- Pantoprazole 40mg by mouth twice daily
Please avoid taking Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs) like ibuprofen or naproxen.
Please call your doctor or come back to the doctor if you vomit
blood, have bright red bowel movements, black bowel movements,
lightheadedness, chest pain, shortness of breath, fevers, chills
or have severe pain.
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 2 [**Doctor Last Name **] Dr, [**Name (NI) 14663**], [**Numeric Identifier 73009**],
([**Telephone/Fax (1) 82683**]. You will see her nurse practictioner on Friday,
[**10-24**] at 10:30am. Please call to confirm the appointment.
It is important you have your blood levels checked to make sure
you are not bleeding.
Additionally, we sent a test for H. pylori, which is an
infection in your GI tract that can cause ulcers. The results
are not back yet. It is very important that you or your primary
care doctor follow up this result. If it is positive, you need
treatment with 'triple therapy' which is an acid medication and
two antibiotics which should eradicate the infection.
Completed by:[**2127-10-27**]
ICD9 Codes: 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4601
} | Medical Text: Admission Date: [**2108-10-10**] Discharge Date: [**2108-10-19**]
Date of Birth: [**2041-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], PDA) [**2108-10-11**]
History of Present Illness:
Patient is a 67-year-old gentleman who has been experiencing
crescendo angina. Stress test and cardiac cath at [**Hospital3 2358**]
demonstrated severe 3-vessel coronary disease. The patient
wished to have his bypass surgery done
here at [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] by myself. He was therefore
transferred to [**Hospital1 69**] from the
[**Hospital3 2358**] with a diagnosis of acute coronary syndrome. The
patient understood the risks and benefits of
the procedure including, but not limited to, bleeding,
infection, myocardial infarction, stroke, death, renal and
pulmonary insufficiency, as well as the possibility of a blood
transfusion and future revascularization procedures,
and agreed to proceed. Extensive discussion was had with the
patient concerning cognitive deficits after cardiac surgery,
both on and off-pump, and he chose to proceed with an on-pump
procedure. All questions were answered to his satisfaction, as
well as his wife's satisfaction prior to proceeding.
Past Medical History:
HTN
Hyperlipidemia
GERD
TIA
CAD
Social History:
Works as electrical engineer
Married, lives with wife
[**Name (NI) 1139**]: denies
Alcohol: rare
Family History:
Father - myocardial infarction
Mother - myocardial infarction
Brother - angina, percutaneous transluminal coronary angioplasty
Physical Exam:
Admission:
Vitals: Blood pressure , Heart Rate , Respiratory Rate , Oxygen
Saturation, Temperature
General: well developed male in no acute distress
HEENT: oropharynx benign, PERRLA,
Neck: supple, full range of motion, no lymphandenopathy,
Carotids +2 without bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, without
masses or heptosplenomegaly
Ext: warm, no edema, no varicosities
Pulses: 2+ bilaterally
Neuro: nonfocal
Pertinent Results:
[**2108-10-18**] 07:10AM BLOOD WBC-6.1 RBC-2.89* Hgb-8.9* Hct-25.9*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.2 Plt Ct-205
[**2108-10-19**] 07:15AM BLOOD PT-16.0* PTT-77.5* INR(PT)-1.5*
[**2108-10-18**] 07:10AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-141
K-4.6 Cl-104 HCO3-30 AnGap-12
[**2108-10-11**] ECHO
PRE-CPB: The left atrium is normal in size. No mass/thrombus is
seen in the left atrium or left atrial appendage. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage. 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. 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 aortic root. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen.
POST-CPB: There is preserved biventricular systolic function on
no inotropic support. MR, AI remain trace. Post CPB aortic
contours are normal.
[**2108-10-16**] CXR
Small bilateral pleural effusions have remained stable or
improved. Left lower lobe atelectasis has nearly cleared. Upper
lungs are clear. Cardiomediastinal silhouette has a normal
postoperative appearance. No pneumothorax. Lateral view shows a
small retrosternal air and fluid collection as likely to be in
the prevascular mediastinum as in the paramedian pleural space.
[**2108-10-13**] ECHO
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
3. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
Brief Hospital Course:
Mr. [**Known lastname 96326**] was admitted to the [**Hospital1 18**] on [**2108-10-10**] for surgical
management of his coronary artery disease. He was worked-up in
the usual preoperative manner. On [**2108-10-11**], Mr. [**Known lastname 96326**] was taken
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for detail.
Postoperatively, he was taken to the cardiac surgical step down
unit for monitoring. By postoperative day one, Mr. [**Known lastname 96326**] was
awake, neurologically intact and extubated. His drains were
removed per protocol. He was transferred to the step down unit
for further recovery. He. was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. The
electrophysiology service was consulted for sinus bradycardia
with a junctional escape rhythm under his epicardial pacer. Beta
blockade was held while his paced rate was slowly decreased. He
was subsequently transferred back to the intensive care unit for
close monitoring. An echocardiogram was performed which showed a
normal ejection fraction. As his intrinsic rhythm recovered, he
was transferred back to the step down unit. His pacing wires
were removed on postoperative day four. The electrophysiology
service saw no need for a pacemaker and recommended starting low
dose beta blockade. Mr. [**Known lastname 96326**] developed some runs of atrial
fibrillation which was rate controlled with beta blockade,
amiodarone and electrolyte repletion. Heparin as a bridge to
coumadin was started for anticoagulation. Mr. [**Known lastname 96326**] continued
to make steady progress and was discharged home on postoperative
day eight. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist
and his primary care physician as an outpatient. He was in
normal sinus rhythm at 67 on discharge. His coumadin dosing will
be followed by Dr. [**Last Name (STitle) **] for a goal INR of 2.0-2.5.
Medications on Admission:
Hydrochlorothiazide 25mg daily
Atenolol 50mg daily
Aspirin 325mg daily
Folic Acid daily
Lovastatin 20mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg [**Hospital1 **] x 1 week then 400mg QD x1 wk then200mg QD.
Disp:*70 Tablet(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day for
1 days: Take as directed by Dr. [**Last Name (STitle) **] for an INR goal of [**3-15**].5.
Disp:*120 Tablet(s)* Refills:*0*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p Coronary Artery Bypass Graft Left internal mammary artery to
left anterior descending, saphaneous vein graft to diagonal and
obtuse marginal, saphaneous vein graft to posterior descending
artery
Atrial Fibrillation
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, rednesss or drainage from wounds
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Followup Instructions:
Dr [**First Name (STitle) 7325**] [**Name (STitle) **] in [**4-14**] weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-14**] weeks
Dr [**Last Name (STitle) 914**] in 4weeks
Completed by:[**2108-10-24**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4602
} | Medical Text: Admission Date: [**2182-7-31**] Discharge Date: [**2182-7-31**]
Date of Birth: [**2121-10-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: ST elevation myocardial
infarction. [**Known firstname **] [**Known lastname 14893**] was a 61-year-old man transferred
acutely from [**Hospital 47**] Hospital after experiencing chest
pain and noting to have ST elevation in the lateral
precordial leads. The patient had a background history of
coronary artery disease, status post coronary artery bypass
graft in [**2171**], stent in [**2176**] and [**2177**]. He also had a history
of diabetes, hypertension, and hypercholesterolemia.
The patient was urgently transferred to the cath lab,
arriving at approximately 1:45 in the morning, at which point
he was awake, alert with a blood pressure of 80 to 90
systolic and complaining of chest pain. His cardiac exam
revealed normal heart sounds and bibasilar rales. Abdominal
exam, neurological exam, musculoskeletal exam were all within
normal limits.
PERTINENT LAB, X-RAY, EKG, AND OTHER TESTS: ECG revealed ST
elevation in V5, V6, I, and aVL. It was felt the patient
needed urgent catheterization, plus or minus stenting for
acute ST elevation myocardial infarction.
The patient underwent coronary angiography revealing
occlusion of his 3 vein grafts and also acute thrombosis of
the distal end of his left internal mammary artery graft to
his left anterior descending artery. The native blood vessels
were chronically occluded proximally.
The procedure was complicated by difficulty in accessing the
vein grafts and establishing which of his blood vessels was
the culprit lesion. The patient had a stent placed to his
distal left internal mammary artery as this anastomosed with
the LAD. This procedure went relatively easily, and there
were no acute complications. However, while the patient was
being brought back to the coronary care unit he vomited on
the way to the elevator and then suffered a cardiac arrest.
The initial rhythm was ventricular tachycardia. Precordial
thump failed to restore a sinus rhythm, so the patient was
shocked once. His rhythm converted to sinus bradycardia, so 1
mg of atropine was given. The patient was resuscitated using
1 further mg of atropine, 1 mg of epinephrine, 300 mg of IV
amiodarone. His rhythm returned to his previous atrial
fibrillation, and he was placed back on the cath lab table.
An intraaortic balloon pump was inserted and a stat bedside
echo done. The echo did not reveal any acute mechanical
complication of his myocardial infarction. Temporary
ventricular pacing and a dopamine infusion were started.
Repeat catheterization showed that the stent to his LIMA was
patent. Because of concern that the anterior descending
artery disease may have caused the cardiac arrest, the
multiple stenoses were attempted to be dilated. However, this
proved to be extremely difficult due to heavy calcification
in the blood vessels. Despite attempting dilatation and
giving increased doses of pressors, atropine, and bicarbonate
the patient was unable to recover a perfusing rhythm and he
died at 06:57 a.m. The family were informed of his death, and
his course in the hospital was explained to them in detail.
CAUSE OF DEATH: Cardiogenic shock from myocardial
infarction.
MEDICATIONS ON DISCHARGE: None obviously.
DISCHARGE FOLLOWUP: None obviously.
[**Known firstname **] [**Last Name (NamePattern4) 839**], [**MD Number(1) 840**]
Dictated By:[**Last Name (NamePattern1) 48854**]
MEDQUIST36
D: [**2183-2-10**] 10:36:51
T: [**2183-2-10**] 11:22:36
Job#: [**Job Number 48855**]
ICD9 Codes: 9971, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4603
} | Medical Text: Admission Date: [**2141-4-7**] Discharge Date: [**2141-4-19**]
Date of Birth: [**2087-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
esophageal cancer t3, N1 s/p neoadjuvent chemo -presents for
resection
Major Surgical or Invasive Procedure:
lap esophagectomy and feeding J-tube
History of Present Illness:
Mr. [**Known lastname 23306**] is a 53-year-old
gentleman who has a T3 N1 adenocarcinoma of the distal
esophagus. He was treated with chemotherapy and radiation in
the neoadjuvant fashion and this had stable to improving
disease and, therefore, presents for resection.
Past Medical History:
Hypertension
Hypercholesterolemia
Bilateral knee arthritis
esophgeal cancer T3, N1
Social History:
Real Estate broker, divorced, two kids- son is HCP. [**Name (NI) **]
smoking history, 44 pack years, stopped [**1-4**]. No EtOH for 23
years.
Family History:
Mother with breast cancer, father with emphysema,
lung cancer and older brother had metastatic melanoma.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.3, pulse 92, blood pressure 138/74,
respiratory rate 16, oxygen saturation 99% on room air, weight
203.7 pounds.
GENERAL: Slightly ill-appearing gentleman, alert and oriented
x3.
HEENT: There is no cervical or supraclavicular lymphadenopathy.
NECK: Supple and nontender.
LUNGS: Clear to auscultation and percussion.
CHEST: Chest excursion is symmetric and good.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended, without mass or
hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2141-4-16**] 05:20PM 11.2* 3.44* 11.4* 32.6* 95 33.1* 35.0
15.7* 349
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2141-4-16**] 05:20PM 349
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-4-16**] 05:20PM 110* 25* 0.7 133 4.9 93* 30 15
barium swallow [**2141-4-12**]
IMPRESSION:
1. Status post esophagectomy with gastric pull-through. Small
contained leak is seen posteriorly along the likely inferior
margin of the cervical anastomosis. Extraluminal contrast most
likely tracks intramurally, and then forms a small collection
posteriorly, but does not extend farther into the mediastinum.
2. Nasogastric tube, with sideport located in the middle of the
gastric pull- through, tube could be advanced approximately [**4-6**]
cm for more optimal positioning.
Brief Hospital Course:
pt admitted and atken tot he OR for Minimally invasive
esophagectomy; mediastinal lymph node dissection, tube
jejunostomy. OR course was uneventful. Epidural was placed and
PCa was also used for pain control. Admitted to the SICU for
post op management. Chest tube was to sxn , anastomotic JP to
bulb sxn and J-tube initially to gravity.
POD#2 passage of flatus. Trophic tube feeds were started and
advance when passing stool and flatus. chest tube was placed to
water seal.
Transfused 2UPRBC for post op anemia. Pt restarted on fent patch
which he had been on PTA.
POD#4 chest tube d/c'd. Epidural d/c'd and mainatined on roxicet
elixir w/ PCA for breakthru.
POD# 6 barium swallow done revealing contained cervical
anastomic leak. JP drainage sent for trigylcerides which was
minimal not consistent w/ a chyle leak. Maintained NPO status
and TF increased to goal. NGT output remained high 700-1000cc.
POD#9 attempted NGT to gavity but pt became nauseous and sxn was
resumed.
POD#10 KUB was done - no ileus.
POD#11 - NGT was d/c'd and pt. started on sips 30 cc/hr - he
tolerated this well
POD#12 - pt. d/c to home
Post op course was complicated by slow return of GI function w/
high NGT output.
Medications on Admission:
Lisinopril 20', toprol xl 25', nicotine patch, wellbutrin 150"
.
Discharge Medications:
1. tube feeding
replete w/ fiber at 90cc/hr continuous
2. feeding pump
feeding pump and supplies
3. flushes
J-tube flushes 50cc every eight hours and before and after tube
feed hook-up and disconnect
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
5. Famotidine 20 mg IV Q12H
6. Metoprolol 7.5 mg IV Q6H
Hold for SBP < 100, HR <55
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
esophageal cancer s/p esophagectomy and feeding J-tube
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) 2347**] [**Telephone/Fax (1) 170**] office if you develop chest
pain, fever, chills, redness or drainage from your incision
sites. Call if you have difficulty swallowing, nausea, vomiting
or diarrhea.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding.
Followup Instructions:
Provider: [**Name10 (NameIs) 326**] UPPER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2141-4-25**] 10:00
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2141-4-25**] 11:30
ICD9 Codes: 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4604
} | Medical Text: Admission Date: [**2139-4-17**] Discharge Date: [**2139-4-20**]
Date of Birth: [**2059-4-12**] Sex: F
Service: NEUROLOGY
Allergies:
Cardizem / Plavix / Prozac / Accupril / Crestor / Topiramate /
Norvasc / Demerol / Bextra / Lescol / Famvir
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness:
The patient is an 80 year old woman with multiple vascular risk
factors now presenting with acute onset left sided weakness and
slurred speech. She was in her usual state of health until
around 9 am today when the son noticed that her left face was
drooping and she wasn't moving her left side. He says she got
up
around 8 am and was initially fine. She had her brought to
[**Hospital3 7571**]Hospital where her symptoms initially seemed to
resolve. About 1 hour later (after CT scan), she acutely
re-developed the left facial droop, "flaccid paralysis" on left
arm and dysarthria. She was started on heparin and transferred
to [**Hospital1 18**] ED for further care.
She had a recent colonscopy where colon CA was discovered. She
underwent a partial colectomy and was admitted to [**Location (un) **] from
[**4-7**] to [**4-15**]. During this time, her warfarin was held. She was
restarted on upon discharge.
Past Medical History:
Past Medical History:
-high blood pressure
-atrial fibrillation
-colon ca s/p resection
-high cholesterol
-CAD s/p pacer
-s/p cataract surgeries
-anxiety
-copd
-gerd
Social History:
Social History:
-lives with daughter
-no smoking or drinking
Family History:
Family History:
-non-contributory
Physical Exam:
Physical Exam
Vitals: 98.6 140/80 88 irreg 16
General: older woman, nad
Neck: supple
Lungs: clear to auscultation
CV: irregular rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, trace edema
Neurologic Examination:
awake, alert, neglecting left side, answering questions but
somewhat dysarthric, able to repeat, naming impaired, following
simple commands; perrl 2 to 1 mm, eyes moving all about, left
facial droop, tone decreased on left side, seems full strength
on
the right, [**2-1**] UMN weakness on left arm and leg, reflexes brisks
and symmetric, toe up on left; responds to pain x4, less so on
left; gait exam deferred
Pertinent Results:
[**2139-4-17**] 05:52PM %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE
[**2139-4-17**] 03:47PM GLUCOSE-126* UREA N-12 CREAT-0.8 SODIUM-144
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-30 ANION GAP-15
[**2139-4-17**] 03:47PM ALT(SGPT)-79* AST(SGOT)-37 LD(LDH)-363*
CK(CPK)-64 ALK PHOS-103 AMYLASE-46 TOT BILI-0.7
[**2139-4-17**] 03:47PM LIPASE-38
[**2139-4-17**] 03:47PM CK-MB-NotDone
[**2139-4-17**] 03:47PM ALBUMIN-3.6 URIC ACID-6.2*
[**2139-4-17**] 03:47PM CRP-62.5*
[**2139-4-17**] 03:47PM PT-17.2* PTT-32.4 INR(PT)-1.6*
[**2139-4-17**] 02:10PM cTropnT-0.01
[**2139-4-17**] 02:10PM CHOLEST-73
[**2139-4-17**] 02:10PM TRIGLYCER-103 HDL CHOL-29 CHOL/HDL-2.5
LDL(CALC)-23
[**2139-4-17**] 02:10PM TSH-3.6
[**2139-4-17**] 02:10PM WBC-9.9 RBC-3.43* HGB-10.6* HCT-31.8* MCV-93
MCH-30.9 MCHC-33.4 RDW-15.8*
[**2139-4-17**] 02:10PM NEUTS-81.3* LYMPHS-13.3* MONOS-5.0 EOS-0.4
BASOS-0.1
[**2139-4-17**] 02:10PM MACROCYT-1+
[**2139-4-17**] 02:10PM PLT COUNT-193
[**2139-4-17**] 02:10PM SED RATE-22*
[**2139-4-20**] 03:41AM BLOOD WBC-23.7* RBC-3.81* Hgb-11.9* Hct-34.9*
MCV-92 MCH-31.1 MCHC-34.0 RDW-15.3 Plt Ct-219
[**2139-4-20**] 11:50AM BLOOD PT-40.6* PTT-110.9* INR(PT)-4.6*
[**2139-4-20**] 03:41AM BLOOD Fibrino-330
[**2139-4-17**] 02:10PM BLOOD ESR-22*
[**2139-4-20**] 03:41AM BLOOD Glucose-125* UreaN-23* Creat-1.6* Na-131*
K-5.1 Cl-95* HCO3-15* AnGap-26*
[**2139-4-20**] 08:31AM BLOOD CK(CPK)-181*
[**2139-4-20**] 03:41AM BLOOD ALT-3233* AST-3967* LD(LDH)-2087*
CK(CPK)-179* AlkPhos-133* Amylase-58 TotBili-1.8*
[**2139-4-20**] 08:31AM BLOOD CK-MB-11* MB Indx-6.1*
[**2139-4-20**] 03:41AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.0
[**2139-4-19**] 12:53PM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.9 Mg-2.0
[**2139-4-17**] 05:52PM BLOOD %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE
[**2139-4-17**] 02:10PM BLOOD Triglyc-103 HDL-29 CHOL/HD-2.5 LDLcalc-23
[**2139-4-20**] 08:31AM BLOOD TSH-1.2
[**2139-4-20**] 08:31AM BLOOD Free T4-1.6
[**2139-4-17**] 03:47PM BLOOD CRP-62.5*
[**2139-4-20**] 12:04PM BLOOD Type-ART pO2-134* pCO2-22* pH-7.29*
calTCO2-11* Base XS--13
[**2139-4-20**] 12:04PM BLOOD Lactate-14.4*
[**2139-4-20**] 12:39PM BLOOD Hgb-12.0 calcHCT-36 O2 Sat-79
[**2139-4-20**] 12:04PM BLOOD freeCa-0.96*
[**2139-4-20**] 12:04PM BLOOD freeCa-0.96*
Brief Hospital Course:
Assessment and Plan:
The patient is an 80 year old woman with multiple vascular risk
factors now presenting with acute onset left sided weakness.
Her
exam shows a left neglect, dysarthria, left sided weakness. She
appears to have a significant territory right MCA stroke,
probably embolic given her subtherapeutic INR. We will admit
her
to neurology and do the following:
1. d/c heparin as her risk of bleeding is high
2. start dopamine and achieve SBP 160-200
3. obtain stat head cta
4. obtain carotid US
5. will check lipid profile
* * *
Ms. [**Known lastname **] had a non-contrast Head CT that revealed hypodensity
in the right subcortical and insular white matter consistent
with infarct. CTA of the head revealed calcifications of the
carotid bifurcations, left greater than right, without
significant stenosis, but otherwise the major tributaries of the
circle of [**Location (un) 431**] were patent. She was admitted to the intensive
care unit due to her need for pressors. While there she began
to exhibit septic physiology, with a WBC up to 24, evidence of
DIC, and lactate as high as 14. She was placed on
broad-spectrum antibiotics but her condition did not improve.
She had an echocardiogram on [**4-20**] that revealed left ventricular
cavity enlargement with severe regional systolic dysfunction c/w
multivessel CAD, right ventricular hypokinesis, and moderate
mitral regurgitation. A chest CTA on [**4-19**] revealed a pulmonary
embolism within a left upper lobe segmental pulmonary artery and
bilateral pleural effusions. As her overall condition continued
to deteriorate, a family meeting was held. Ms. [**Known lastname 49482**]
siblings asserted that she would never want to be dependent on
others, even if it was for a few months. Given her stroke, this
was almost a certainty, and it could not be said that she would
ever recover her independence fully. This fact, taken together
with her deteriorating overall condition, brought her family to
decide that in accordance with her previously expressed wishes,
care would be withdrawn. Hence on [**4-20**] care was withdrawn and
Ms. [**Known lastname **] [**Last Name (Titles) **].
Medications on Admission:
Medications:
-asa 81
-warfarin
-avapro
-imdur
-metformin
-spiriva
-clonazepam
-lasix
-zetia
-lipitor
-fish oil
-nifedipine
-toprol xl
Discharge Medications:
None
Discharge Disposition:
[**Last Name (Titles) **]
Discharge Diagnosis:
Right middle cerebral artery infarct
Sepsis
Discharge Condition:
[**Last Name (Titles) **]
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5990, 0389, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4605
} | Medical Text: Admission Date: [**2133-12-20**] Discharge Date: [**2133-12-25**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
Pericardial window/RV repair [**12-20**]
Right pleural chest tube placement [**12-20**]
History of Present Illness:
[**Age over 90 **]yo woman s/p PPM on [**2133-12-19**] returned to emergency room c/o
shortness of breath and chest pain, found to have large right
hemothorax. Subsequent echocardiogram revealed large pericardial
effusion with tamponade physiology
Past Medical History:
Afib/SSS s/p PPM placed [**12-17**]
HTN
HOH
pulmonary fibrosis
^chol
Social History:
widowed
lives in [**Hospital3 **]
no tobacco
occais ETOH
Family History:
nc
Physical Exam:
Admission
VS T HR 40's BP 40-50/30 RR 12 O2sat 100%NRB
Gen NAD
HEENT EOMI, neck supple
Chest diminished BS right
CV RRR. c/ chest pain
Abdm soft NT/ND
Ext warm, no c/e/e
Discharge
VS T 98.2 HR 79 BP 105/61 RR 18 O2sat 95%-RA
Gen NAD
Neuro Alert, non-focal exam
Pulm diminshed at bases but clear
CV RRR, Rt anterior chest wound-no erythema/CDI
Abdm soft, NT/+BS
Ext warm, trace edema
Pertinent Results:
[**2133-12-20**] 04:57PM GLUCOSE-113* LACTATE-3.3* K+-3.9
[**2133-12-20**] 02:39PM LACTATE-5.0*
[**2133-12-20**] 01:07PM UREA N-20 CREAT-1.1 SODIUM-141 CHLORIDE-110*
TOTAL CO2-18*
[**2133-12-20**] 01:07PM WBC-11.9* RBC-3.17* HGB-10.0*# HCT-29.5*
MCV-93 MCH-31.7 MCHC-34.1 RDW-13.9
[**2133-12-20**] 01:07PM PLT COUNT-100*
[**2133-12-20**] 01:07PM PT-15.8* PTT-34.0 INR(PT)-1.4*
[**2133-12-24**] 06:30AM BLOOD WBC-7.7 RBC-2.87* Hgb-9.3* Hct-26.3*
MCV-92 MCH-32.5* MCHC-35.5* RDW-13.9 Plt Ct-137*
[**2133-12-24**] 06:30AM BLOOD Plt Ct-137*
[**2133-12-21**] 01:35AM BLOOD PT-15.0* PTT-32.7 INR(PT)-1.3*
[**2133-12-24**] 06:30AM BLOOD Glucose-94 UreaN-24* Creat-0.9 Na-140
K-4.4 Cl-103 HCO3-31 AnGap-10
[**Known firstname **] [**Medical Record Number 66310**] F 96 [**2037-10-10**]
Final Report
TYPE OF EXAMINATION: Chest AP portable single view
INDICATION: Status post pericardial window. Evaluate for
pneumothorax.
FINDINGS: AP single view of the chest obtained with patient in
sitting
upright position is analyzed in direct comparison with the next
preceding
similar study obtained four hours earlier during the same day.
Comparison of the films demonstrates that a previously present
right-sided chest tube has been removed. The earlier seen small
right-sided apical pneumothorax has not changed significantly in
size. No new parenchymal abnormalities are identified. Position
of previously described right internal jugular approach central
venous line unchanged and terminating in upper area of the right
atrium. Left-sided permanent pacer with dual electrode system
unaltered.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2133-12-24**] 5:45 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 66311**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 66312**]Portable TTE
(Focused views) Done [**2133-12-24**] at 11:20:16 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2037-10-10**]
Age (years): [**Age over 90 **] F Hgt (in): 66
BP (mm Hg): 107/50 Wgt (lb): 125
HR (bpm): 89 BSA (m2): 1.64 m2
Indication: Pericardial effusion.
ICD-9 Codes: 424.0, 423.3
Test Information
Date/Time: [**2133-12-24**] at 11:20 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**]
[**Last Name (un) 16813**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W058-0:00 Machine: Vivid [**8-16**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Findings
This study was compared to the prior study of [**2133-12-20**].
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or
pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The atria are dilated. There is symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
very small pericardial effusion, posterior to the left atrium,
without significant hemodynamic effects.
IMPRESSION: Very small loculated pericardial effusion.
Compared with the prior study (images reviewed) of [**2133-12-20**],
the patient is now in atrial fibrillation. Pericardial effusion
has been largely drained, and tamponade physiology has resolved.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2133-12-24**] 12:52
,[**Known firstname **] [**Medical Record Number 66310**] F 96 [**2037-10-10**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2133-12-22**]
9:23 PM
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p pericardial window
REASON FOR THIS EXAMINATION:
eval for CVA in pt w word finding difficulties
CONTRAINDICATIONS FOR IV CONTRAST:
None.
PFI AUDIT # 1 RSRc TUE [**2133-12-22**] 11:40 PM
No hemorrhage or edema. Chronic small vessel ischemic disease
and generalized atrophy.
Preliminary Report !! PFI !!
No hemorrhage or edema. Chronic small vessel ischemic disease
and generalized atrophy.
Consider MR if there is concern for acute stroke .
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
PFI entered: WED [**2133-12-23**] 10:34 AM
Brief Hospital Course:
The patient was admitted via the emergency room to the operating
room for emergent pericardial window. At time of admission she
was complaining of chest pain and shortness of breath. She was
found to have significant right hemothorax, subsequent
echocardiogram showed a large pericardial effusion with
tamponade physiology.
The patient was brought to the operating room where she had an
emergent pericardial window via right anterior approach, please
see OR reprt for details. She tolerated the operation well and
post-operatively was transfered to the cardiac surgery ICU. She
did well in the immediate post-op period and was extubated. On
POD 1 she was transferred to the step down floor for continued
post operative care. Once on the floor she was noted to be
slightly aphasic and an emergent head CT and neurology consult
were obtained. The head CT was negative for new infarcts.
Over the next several days she had an uneventful postoperative
course, all tubes lines and drains were removed and her
medications were optimized. On POD 5 she was discharged to
rehabilitation.
Medications on Admission:
univasc 15'
Norvasc 10'
Lipitor 20'
Amiodarone 100'
Plavix 75'
Celebrex 100'
MVI
[**Doctor First Name **]-prn
Tylenol-prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for allergies.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-11**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed.
17. Celebrex 100 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
s/p Pericardial window/RV repair [**12-20**]
Right hemothorax s/p chest tube drainage [**12-20**]
PMH:
Afib/SSS s/p PPM [**2133-12-19**]
CVA
HTN
pulmonary fibrosis
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr [**Last Name (STitle) 7772**] in 4 weeks
Dr [**Last Name (STitle) 66313**] [**Hospital 66314**] clinic in [**2-11**] weeks
Dr. [**Last Name (STitle) **] (neuro) in [**3-16**] weeks. ([**Telephone/Fax (1) 2532**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2133-12-25**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4606
} | Medical Text: Admission Date: [**2193-4-7**] Discharge Date: [**2193-5-2**]
Date of Birth: [**2117-1-19**] Sex: M
Service: Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old man
with a history of chronic obstructive pulmonary disease,
coronary artery disease, status post four vessel coronary
artery bypass graft, mitral valve replacement, left ventricle
pseudoaneurysm with thrombus who was admitted to the Medical
Intensive Care Unit with respiratory distress and hypercarbic
respiratory failure.
Four days prior to admission the patient began to have
progressively worsening shortness of breath with increasing
oxygen requirement and orthopnea. The patient went to the
Emergency Room where he was found to be afebrile and had
diffuse wheezes. He was admitted to the hospital with a
presumptive diagnosis of chronic obstructive pulmonary
disease exacerbation. On the medical floor he was treated
with Solu-Medrol 60 mg intravenously for five doses and
Albuterol, Atrovent nebulizers without significant
improvement for two days. His oxygen saturation was
decreased to 86% with exertion, so he was started on empiric
Levofloxacin given his slow improvement. On the morning of
[**4-10**], the patient began to have chest pain and shortness
of breath. The chest pain was 4 out of 10, typical for his
angina and had desaturations into the 70s on 2 liters by
nasal cannula, increased to 6 liters, improved to 84% oxygen
saturation and 90% on 100% nonrebreather. An
electrocardiogram showed questionable MATs with heart rate
in the 120s and possible ST depressions in V3. He received
sublingual nitroglycerin with resolution of chest pain.
Chest x-ray was obtained that showed a right lower lobe
consolidation that was initially thought to be fluid
overload. He was subsequently given a total of 160 mg of
intravenous Lasix but continued to desaturate with
fluctuating oxygen requirement and arterial blood gases.
Arterial blood gases was obtained with values of pH 7.33,
pCO2 57 and pO2 of 64 on 6 liters by nasal cannula. He was
then transferred to the Medical Intensive Care Unit for
further management of his respiratory failure.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post four vessel coronary
artery bypass graft, porcine mitral valve replacement in
[**2189**], complicated by mediastinitis.
2. Left ventricular pseudoaneurysm with thrombus diagnosed
by transesophageal echocardiogram, [**4-4**].
3. Chronic obstructive pulmonary disease on home oxygen at 2
liters, baseline carbon dioxide in the 48 to 52 range.
Multiple hospital admissions, last in [**2193-2-7**].
Pulmonary function tests in [**2189-12-9**] revealed an FVC of
1.84 (41 percent), FEV1 0.94 (32 percent), FEV/FVC 51 (77%).
4. Atrial fibrillation.
5. Peptic ulcer disease.
6. Bilateral carotid stenosis, status post stent placement
in the left carotid in [**2192-9-7**].
7. Gastrointestinal bleed in [**2191-4-8**], large lower
gastrointestinal bleed with angiectasias in the cecum, also
found to have internal hemorrhoids and diverticuli.
Esophagogastroduodenoscopy showing hiatal hernia and
gastritis, the patient has had multiple bleeds on Plavix in
[**2191**] and [**2192**] resulting in melena.
8. Pulmonary hypertension.
9. Chronic renal insufficiency, baseline creatinine 1.3 to
1.5.
10. Gastroesophageal reflux disease.
11. Status post polypectomy and cholecystectomy.
ALLERGIES: Penicillin, Ancef, Vancomycin, question of
anaphylaxis, Procainamide.
MEDICATIONS ON TRANSFER: Levofloxacin 250 mg p.o. q.d. day
#2, Prednisone 60 mg q.d., Lasix 40 mg q.d., Albuterol,
Atrovent nebulizers q. 6 hours, subcutaneous heparin,
Protonix 40 mg q.d., Fluticasone 110 mcg 2 puffs b.i.d.,
Salmeterol 50 mcg b.i.d. Regular insulin sliding scale.
Senna and Colace.
SOCIAL HISTORY: The patient lives with his wife, remote
smoking history, 40 pack years and no alcohol use. He is a
retired firefighter with possible asbestos exposure in the
past.
PHYSICAL EXAMINATION: On transfer to medicine Intensive Care
Unit - Temperature 98.1, blood pressure 144/75, heart rate
87, respiratory rate 20 to 30. Oxygen saturation 92% on 50%
facemask. Head, eyes, ears, nose and throat showed equal
pupils, round and reactive to light. Dry mucous membranes.
Neck was supple with no jugulovenous distension.
Jugulovenous pressure was approximately 6 cm. The patient
was tachycardiac with a III/VI holosystolic murmur heard at
the left upper sternal border radiating to the axilla. Lungs
had diffuse expiratory wheezes with decreased air movement.
Abdomen was soft, normal bowel sounds, well healed scar.
Extremities had 2+ pitting edema, left greater than right,
but were warm with strong pulses. Neurologically, he was
oriented to self and date. He was minimally cooperative with
the examination but was able to follow simple commands.
LABORATORY DATA: Pertinent laboratory values on transfer to
the Medicine Intensive Care Unit showed laboratory data
notable for a white count of 23.1 and arterial blood gases
with a pH of 7.31, pCO2 59, pO2 of 62 on 10 liters,
saturating 93%. Pertinent imaging - Chest x-ray showed
bilateral pleural effusions, left greater than right,
hyperinflation with cardiomegaly and pleural thickening with
a possible left lower lobe consolidation with no evidence of
pulmonary edema. An electrocardiogram showed inconsistent P
wave morphology with right bundle branch block, [**Street Address(2) 1766**]
depression in V3 and minimal T wave inversion in V1 and V2.
HOSPITAL COURSE: (In the medical Intensive Care Unit by
issue)
1. Respiratory failure - On arrival in the Medicine
Intensive Care Unit, the patient was placed on BiPAP and
continued to have relatively good arterial blood gases. The
patient continued to improve and was on antibiotics and
continued steroid treatment and was returned to the Medical
Floor on [**2193-4-13**]. Later that night the patient began
to desaturate again on the medical floor to the 90s. A blood
gas was drawn that showed a pH of 7.25, pCO2 of 76 and pO2 of
90. The patient appeared to be tiring and was intubated. An
earlier sputum culture grew out Methicillin-resistant
Staphylococcus aureus and the patient was started on
Linezolid due to his Vancomycin allergy. He continued to
improve and was extubated on [**4-19**]. He remained on BiPAP
for a short period of time and was soon transitioned oxygen
by facemask and subsequently nasal cannula. The patient was
initially on intravenous steroids for chronic obstructive
pulmonary disease exacerbation which was changed to
Prednisone and slowly tapered over his hospital course.
2. Atrial fibrillation/atrial flutter - The patient had
brief episodes of atrial fibrillation upon arrival into the
Medical Intensive Care Unit with pressure drops to systolics
of 80s. The rate was controlled with a Diltiazem drip at
this time. Upon returning to the floor on [**4-13**], he again
went into atrial fibrillation with difficulty in controlling
his rate despite being on the Diltiazem drip. He became
hypotensive and was transferred back to the Medicine
Intensive Care Unit. He continued to have a high heart rate
in the 140s with hypertension. Electrophysiology was
consulted and it was decided that the patient should be
cardioverted. He was placed on Amiodarone and remained in
normal sinus rhythm until [**4-22**], when he was transferred
back to the Medical Floor. Shortly thereafter the patient
again went into atrial fibrillation with heart rate in the
140s and systolics in the 70s. Cardiology was again
consulted and it was decided to transfer the patient back to
the Medicine Intensive Care Unit for possible cardioversion.
Upon arrival in the Medicine Intensive Care Unit the
patient's blood pressure had improved and he was placed on a
Diltiazem drip, but again became hypotensive, so the
Diltiazem drip was discontinued. The patient was then placed
on Digoxin the following day when electrophysiology was
consulted. The patient was cardioverted, remained on
Amiodarone and Digoxin. Following this he remained in normal
sinus rhythm until he was transferred back to the Medical
Floor.
3. Thrombocytopenia - The patient's platelets continued to
dwindle down to a level of 53,000. His antibodies were
negative. Proton pump inhibitor was held briefly. The
patient developed melena so it was restarted. Hematology was
consulted and thought that the Linezolid might be the leading
candidate for thrombocytopenia. Since the patient had
finished a ten day course of Linezolid the antibiotic was
discontinued.
4. Gastrointestinal bleed/anemia - The patient had multiple
episodes of melena with guaiac positive stools and received
multiple transfusions with a goal of hematocrit above 30%.
The patient remained on his home regimen of Nexium.
Gastroenterology was initially consulted and deferred doing
an esophagogastroduodenoscopy unless the patient began to
have a brisker bleed. By the end of the Medicine Intensive
Care Unit stay the hematocrit was remaining stable.
5. Chronic obstructive pulmonary disease - The patient
received frequent Albuterol/Atrovent nebulizers and was
treated with steroids initially intravenous that was changed
to Prednisone and tapered.
6. Left superficial femoral vein thrombosis - The patient
had very edematous lower extremities. Ultrasound was
obtained which showed a new left superficial femoral vein
thrombosis. Although the patient had three indications for
anticoagulation with atrial fibrillation, thrombosis in the
left ventricle thrombus, the patient could not be
anticoagulated prior and continued with gastrointestinal
bleed. On [**2193-4-11**], an inferior vena cava filter was
placed by Dr. [**First Name (STitle) **], left ventricular pseudoaneurysm.
Thoracic surgery and Dr. [**First Name (STitle) **] followed the patient while in
the Medicine Intensive Care Unit. Repair of mitral valve
leak and pseudoaneurysm was deferred until after recovery
from current illness.
For the remainder of this discharge summary, please see the
addendum on [**2193-4-28**], dictated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 30936**]
MEDQUIST36
D: [**2193-5-1**] 19:58
T: [**2193-5-1**] 20:18
JOB#: [**Job Number 30937**]
ICD9 Codes: 4280, 5849, 2875, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4607
} | Medical Text: Admission Date: [**2167-2-9**] Discharge Date: [**2167-2-13**]
Date of Birth: [**2117-1-14**] Sex: M
Service: BLOOMGART
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old man
with past medical history of Child's class C cirrhosis
secondary to alcohol hepatitis C, currently on the transplant
list, history of multiple upper gastrointestinal bleeds
secondary to varices status post recent Medical Intensive
Care Unit admission with bright red blood per rectum in
[**12/2166**] who presents with increasing confusion, fatigue,
nausea, and lower extremity swelling times three to four
days.
Per his sister, he has been increasingly confused at home,
walking into the wrong rooms, forgetting to take meds,
including insulin and Lactulose, urinating on the floor
inappropriately. He has had nausea and decreased appetite
and p.o. intake for several weeks more so in the past few
days. Overall he has noted a big decrease in his energy
level, having suffered fatigue after one flight of stairs.
This has been exacerbated by insomnia. He was recently
started on Trazodone with no relief of his insomnia. His
lower extremity edema has been worse, as well.
Recent colonoscopy with Dr. [**Last Name (STitle) 497**] on [**2167-1-27**] noted marked
tortuosity of hepatic flexure resulting in interruption of
exam. Also noted were non-bleeding grade 1 hemorrhoids and
colonic varices of hepatic flexure, not actively bleeding.
Patient denies any fevers, chills, chest pain, shortness of
breath, abdominal pain, increased abdominal girth, emesis,
diarrhea, constipation, melena, hematochezia, bright red
blood per rectum. No dysuria, frequency, cough, sputum, sore
throat.
PAST MEDICAL HISTORY:
1. Child's class C cirrhosis secondary to alcohol hepatitis
C, on the transplant list, with prior history of ascites and
encephalopathy.
2. Hepatitis C diagnosed in [**2159**].
3. Multiple upper gastrointestinal bleeds secondary to
varices status post Medical Intensive Care admission in
[**12/2166**] for melena and bright red blood per rectum, status
post banding of grade 2 non-bleeding varices, EGD with portal
gastropathy.
4. Peptic ulcer disease.
5. Transjugular intrahepatic portosystemic shunt procedure
in [**5-/2166**] placed secondary to variceal bleeding with
revision in [**12/2166**] after ultrasound showed stenosis.
6. Hemorrhoids.
7. Diabetes mellitus type 2.
8. History of lumbar disc herniation.
MEDICATIONS PRIOR TO ADMISSION:
1. Insulin.
2. Ursodiol 600 b.i.d.
3. Spironolactone 50 q. day.
4. Protonix 40 b.i.d.
5. Lactulose.
6. Calcium carbonate 500 q.i.d.
7. Mycelex troches five per day.
8. Sucralfate 1 gram q.i.d.
9. Nadolol 20 q.d.
ALLERGIES: Patient reports no known drug allergies.
SOCIAL HISTORY: Patient lives with his mother. [**Name (NI) **] is
unemployed, a former construction worker. He reports
occasional tobacco down from one pack per day times 20 years.
No alcohol intake for two years. Former intranasal cocaine
abuser as well as intravenous drug user during the [**2132**].
FAMILY HISTORY: Significant for his mother with diabetes and
his father with alcoholic cirrhosis. Father died at age 68.
PHYSICAL EXAMINATION UPON ADMISSION: Vital signs show a temp
of 96.4, blood pressure of 130/54, heart rate 80, respiratory
rate 18, oxygen saturation 98% on room air. General
appearance: Well developed, well nourished male, ill
appearing, jaundiced, no acute distress. HEENT:
Normocephalic, atraumatic; icteric membranes with
conjunctival, buccal, and sublingual icterus; arcus senilis;
pupils equal, round, reactive to light; oral mucosa dry;
oropharynx is clear. Neck: Supple; no masses or
lymphadenopathy; prominent A and D waves; no jugular venous
distention. Lungs: Chest wall with no evident gynecomastia;
lung bases dull to percussion; bibasilar crackles, otherwise
clear to auscultation bilaterally; no egophony. Cardiac:
Regular rate and rhythm; normal S1 and S2; harsh, loud III/VI
early systolic murmur heard best at the lower left sternal
border with radiation to the axilla consistent with mitral
regurgitation versus tricuspid regurgitation; no rubs or
gallops. Abdomen: Soft; moderate right lower quadrant
tenderness; no fluid wave; no palpable ascites; positive
normal active bowel sounds. Rectal exam: Guaiac negative by
the Emergency Department staff. No hepatomegaly. Spleen
enlarged with palpable tip four fingerbreadths below the
costal margin; no caput medusa. Extremities: 2+ pitting
bilateral lower extremity edema to the knees; positive palmar
erythema and teres nails. Neurological: Moderate asterixis;
moving all extremities; cranial nerves II-XII grossly intact.
Skin: Jaundiced; palmar erythema; multiple spider
telangiectasias over the chest wall.
PERTINENT LABORATORY DATA, X-RAYS, OTHER STUDIES: White
blood cell count on admission showed WBC 4.8, hematocrit
37.8, MCV 100, platelets 88. Coagulation profile showed a PT
of 19.3, PTT 47.8, INR 2.5 up from 2.3 on [**2167-2-4**] notably
also up from 1.9 on [**2167-1-21**]. Serum chemistry showed a
sodium 133, potassium 3.4, chloride 102, bicarbonate 26, BUN
11, creatinine 0.7, glucose 264. Liver function tests showed
ALT 114, AST 182, amylase 69, alkaline phosphatase 230,
lipase 84, albumin 4.5 which appears to be spurious, total
protein 6.7, ammonia 58, total bilirubin 25.6 up from 10.4
[**2167-1-21**].
Chest x-ray showed no acute cardiopulmonary process.
Ultrasound of the abdomen showed no demonstrable remarkable
ascites, transjugular intrahepatic portosystemic shunt
patent.
Serial blood cultures and urine cultures at the time of this
dictation failed to show any significant bacterial growth.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Cirrhosis with end-stage liver disease: Patient is on
the transplant list. Although he has been slowly declining,
he has had an acute decompensation in the last three to four
days to one week prior to this admission. This was
concerning for spontaneous bacterial peritonitis, other
infection, bleeding, [**Last Name (un) **]-occlusive disease, and/or blockage
of TIPS.
He was followed with serial hematocrits throughout bleeding;
all stools were guaiac. There was no evidence of bleeding
during this admission. Right upper quadrant ultrasound was
performed due to assess patency of the TIPS and to assess for
ascites. Ultrasound demonstrated patency of the TIPS and no
ascites. We followed his renal function closely out of
concern for hepatorenal syndrome. During admission
creatinine appeared to increase slowly each day. Blood and
urine cultures were sent to rule out systemic infection.
Serial cultures failed to reveal any source of infection.
Initially he had no antibiotic coverage.
However, during hospital course on [**2167-2-12**] he developed a
new onset of cough with clinically significant areas of
rhonchi and crackles on his lung exam concerning for
pneumonia. As such, he began a seven- to 10-day course of
Levaquin at that time.
Lactulose was continued for encephalopathy. Dose was
increased from 30 to 45 ml q.i.d. titrated to four to five
bowel movements per day. Even so, the patient remained
encephalopathic with moderate asterixis on exam. Diuretics
were initially continued at his outpatient dose as we felt he
was intravascularly dry with total volume overloaded. This
was likely from loss of albumin as an intravascular oncotic
force. After development of a respiratory infection
concerning for pneumonia, diuretics were held out of concern
that increased secretions and ........... losses will lead
the patient to dehydration in the setting of diuretics use,
as well.
Nadolol was continued as prophylaxis against variceal
bleeding. Coagulation performed. Albumin and bilirubin were
followed as markers of liver function were calculated the
patient's meld score.
2. Questionable pneumonia versus bilateral effusions: On
admission there was some concern for a possible pneumonia.
Chest x-ray was evaluated which demonstrated no acute
cardiopulmonary disease. As such, the patient was not
initially covered on antibiotics. However, during this
hospital course his lung exam deteriorated and he began to
have a cough productive of brownish/tan sputum.
At this time chest x-ray was repeated with [**Location (un) 1131**] consistent
with bilateral opacities concerning for infection versus
pulmonary edema. In light of the concern for infection,
patient was started on Levaquin. He will likely complete a
seven- to 10-day course.
3. Diabetes mellitus type 2: In order to optimize the
patient pending hopefully upcoming liver transplant, the
[**Last Name (un) **] Diabetes Center was consulted for recommendations on
better insulin control. Patient was continued on a Humalog
insulin sliding scale with the addition of NPH after
initiation of tube feeds resulted in profound hyperglycemia.
[**Last Name (un) **] team continued to make recommendations, which was
appreciated.
4. Peptic ulcer disease: Patient continued on his
outpatient dose of proton pump inhibitor.
5. Fluid, electrolytes, and nutrition: As an outpatient
patient had undergone a Nutrition consult. Patient was
revealed that he was not meeting his daily caloric needs
through oral intake alone. As such, during this
hospitalization a post pyloric feeding tube was placed under
fluoroscopy and Ultracal tube feeds were initiated in order
to optimize the patient from a nutritional standpoint pending
hopeful upcoming transplantation.
DISCHARGE CONDITION: Guarded, afebrile, hemodynamically
stable, hematocrit and INR stable, tolerating oral intake
with tube feeding supplementation, ambulating independently,
mental status at baseline.
DISPOSITION: Discharged to home with services.
DISCHARGE DIAGNOSES:
1. End-stage liver disease secondary to alcoholic- and
hepatitis C-related cirrhosis with history of ascites,
variceal bleeding, encephalopathy.
2. Hepatitis C.
3. History of upper gastrointestinal bleed secondary to
varices status post banding.
4. Peptic ulcer disease.
5. Status post transjugular intrahepatic portosystemic shunt
procedure.
6. Hemorrhoids.
7. Diabetes mellitus type 2.
8. History of lumbar disc herniation.
DISCHARGE MEDICATIONS:
1. Ursodiol 600 mg p.o. b.i.d.
2. Spironolactone 50 mg p.o. q.d.
3. Pantoprazole 40 mg p.o. q. 12 hours.
4. Calcium carbonate 500 mg p.o. q.i.d.
5. Clotrimazole troche 10 mg, one troche, five times a day.
6. Sucralfate 1 gram p.o. q.i.d.
7. Nadolol 20 mg p.o. q.d.
8. Fluticasone 110 mcg aerosol metered-dose inhaler, two
puffs inhaled, q. day.
9. Lactulose 45 ml p.o. q.i.d. titrated to four or five
bowel movements daily.
DISCHARGE INSTRUCTIONS:
1. Patient already had an appointment scheduled with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in the [**Hospital Unit Name **] Transplant Center on
[**2167-2-18**] at 1 p.m.
2. He will have visiting nursing and physical therapy
services at home.
3. He will also have [**Hospital1 5065**] Home Care in order to assist with
tube feeding supplies and administrations.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**]
Dictated By:[**Last Name (NamePattern1) 48101**]
DD: [**2167-2-13**] 13:58
DT: [**2167-2-14**] 08:45
JOB#: [**Job Number 48102**]
cc: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
ICD9 Codes: 486, 4280, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4608
} | Medical Text: Admission Date: [**2139-1-1**] Discharge Date: [**2139-1-6**]
Date of Birth: [**2067-7-29**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Ventricular fibrillation and tachycardia
Major Surgical or Invasive Procedure:
Internal cardiac defibrillator placement
History of Present Illness:
71yo M with ischemic CM, last EF 20-25%, CKD, DM, PAD with
recurrent nonhealing ulcers and s/p multiple bypass/grafts. ECG
shows signs of old inferior MI. EF dropped to 20% in [**2-/2138**] so
patient underwent cardiac catheterization via radial access in
5/[**2138**]. Found to have 70% prox RCA (no intervention) and 80%
prox Lcx (unable to stent but POBA'd). Pt has not had any chest
pain. Repeat echo in [**9-/2138**] unchanged. Saw Dr. [**First Name (STitle) 437**] who
suggested ICD and continued lisinopril 2.5mg daily and Toprol XL
50mg daily); uptitration limited by BP. Over past 3 weeks, he
reports intermittent episodes of lightheadedness after walking,
sometimes associated with nausea, that gradually subsides. He
saw [**Doctor Last Name **] on [**12-24**] and was orthostatic so metolazone was stopped
but he was kept on Lasix 60mg [**Hospital1 **].
.
The patient sat down today at dinner table and felt dizzy and
nauseated. He didn't realize he had syncopized but witnessed by
family who called EMS, no head trauma. EMS noted a pale
appearance and found him to be in monomorphic VT on telemetry.
His blood pressures remained stable (documented BP 107/68), and
he broke spontaneously into sinus rhythm.
.
On ED arrival, VS: P 70, BP 106/74, RR 18, O2sat 100%. He again
went into VT on arrival and became unresponsive although with a
pulse. As pads were being placed, he woke up and went into
sinus rhythm. As amiodarone was ordered, he again went into VT
and became unresponsive, this time thought to be pulseless. He
was emergently shocked with 200J with restoration of sinus
rhythm. He was bolused amiodarone and started on gtt. He was
also given calcium gluconate due to concern for hyperkalemia in
setting of chronic renal failure; hemolyzed K 6.4 on arrival;
repeat K 1/2 hour later was 4.6. He received a total of 1L IVF
in the ED. CXR unremarkable. On transfer, Afebrile P 86, BP
96/63 (80s-90s baseline), RR 16, O2sat 96% RA.
.
On review of systems, he endorses chronic LBP, h/o pulmonary
emboli. S/He denies any prior history of stroke, TIA, bleeding
at the time of surgery, myalgias, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative. Denies dysuria, urgency,
frequency.
.
Cardiac review of systems is notable for presence of syncope and
for the absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: CAD s/p silent IMI
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**5-/2138**] cath with
diffusely calcified LAD, 80% prox LCx s/p PTCA and calcified
proximal and mid 70% stenoses.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- Type 2 diabetes mellitus with neuropathy
- Cardiomyopathy with LVEF of 20%
- Severe PAD with multiple leg procedures followed by Dr.
[**Last Name (STitle) **].
- Protein S deficiency
- Anti-phospholipid antibody syndrome (positive lupus
anticoagulant)
- Pulmonary emboli in [**2128**] and [**2129**] s/p IVC filter placement in
[**2-/2138**], off Coumadin due to UGIB
- Erosive gastritis complicated by UGIB
- Gout, exacerbated by HCTZ
- s/p panniculectomy in [**2128**]
- s/p debridement of right foot [**2135-4-9**]
- chronic low back pain
- Hypothyroidism
Social History:
-Tobacco history: Never smoker.
-ETOH: former heavy, sober x many years, decided to have 2 beers
with a friend today.
-Illicit drugs: denies.
Patient lives in [**Hospital1 392**] with his wife and daughter. [**Name (NI) **] is a
retired maintenance technician.
Family History:
Father died at 54 of Alzheimer's disease.
Mother with diabetes mellitus.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Arrival
VS: T=96.9 BP=106/79 HR=83 RR=16 O2 sat=96% 3L NC
GENERAL: WDWN Caucasian male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Skin graft over R foot intact.
PULSES:
Right: Carotid 2+ Femoral 1+ DP dopp PT dopp
Left: Carotid 2+ Femoral 1+ DP 1+ PT 1+
Pertinent Results:
Admission
[**2139-1-1**] 08:15PM BLOOD WBC-7.3 RBC-4.14* Hgb-13.7* Hct-39.4*
MCV-95 MCH-33.2* MCHC-34.9 RDW-18.4* Plt Ct-188
[**2139-1-1**] 08:15PM BLOOD PT-22.3* PTT-32.8 INR(PT)-2.1*
[**2139-1-1**] 08:15PM BLOOD Glucose-260* UreaN-66* Creat-2.4* Na-136
K-6.9* Cl-105 HCO3-18* AnGap-20
[**2139-1-1**] 08:15PM BLOOD ALT-16 AST-59* CK(CPK)-104 AlkPhos-106
TotBili-0.2
[**2139-1-1**] 08:15PM BLOOD cTropnT-0.10*
[**2139-1-1**] 08:15PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.4 Mg-1.8
[**2139-1-1**] 08:24PM BLOOD Glucose-256* Lactate-5.8* Na-138 K-7.1*
Cl-105 calHCO3-18*
.
=======================IMAGES==============================
CXR
Please note the extreme right costophrenic angle is excluded
from
view. Lung volumes are diminished. No consolidation or edema is
evident.
Calcified pleural plaques are again evident consistent with
prior asbestos
exposure. The mediastinum is grossly unremarkable. The cardiac
silhouette is exaggerated by low lung volumes but likely grossly
top normal for size. No large effusion or pneumothorax is noted
within limitations. Degenerative changes are seen throughout the
thoracic spine.
.
IMPRESSION: Relatively stable chest x-ray examination within
limits. No
focal consolidation noted. There are underlying calcified
plaques from prior asbestos exposure.
.
.
CXR post placement: The patient is slightly rotated to the left.
A left pectoral ICD leads terminate in the expected locations of
the right atrium and right ventricle. Pleural plaques are likely
due to prior asbestos exposure. The cardiac and mediastinal
silhouettes and hilar contours are normal. There is no pleural
effusion or pneumothorax.
IMPRESSION: ICD leads terminate in right atrium and right
ventricle.
==========================DC Labs
================================
[**2139-1-6**] 06:00AM BLOOD WBC-7.7 RBC-3.89* Hgb-12.6* Hct-36.8*
MCV-95 MCH-32.4* MCHC-34.2 RDW-18.4* Plt Ct-181
[**2139-1-6**] 06:00AM BLOOD Glucose-210* UreaN-52* Creat-2.2* Na-139
K-4.5 Cl-100 HCO3-29 AnGap-15
[**2139-1-6**] 06:00AM BLOOD Mg-2.1
[**2139-1-3**] 06:40AM BLOOD TSH-1.4
Brief Hospital Course:
ASSESSMENT AND PLAN: 71yo M with CAD s/p silent inferior MI and
subsequent ischemic cardiomyopathy with last EF 20%, CKD, HTN,
DM, HLD who presents after monomorphic VT arrest at home with
ROSC and now s/p pulseless VT/VF arrest in the [**Hospital1 18**] ED, now HD
stable.
.
# RHYTHM: now s/p VT/VF arrest and now in sinus again on
amiodarone gtt. [**Month (only) 116**] be related to old scar from known prior
ischemia. EP initially wanted cath, but interventional did not
feel it was necessary, CT [**Doctor First Name **] ddid't feel that
revascularization was warranted, so ultimately the patient was
monitored clinically and an ICD was placed. We also started him
on amiodarone first IV, then transitioned to PO prior to
discharge, with instructions to half the dose a week later and
take 1 pill indefinitely. We also decreased his warfarin, given
interaction with amiodarone and gave him a script for INR check
on [**1-8**], with follow-up with Dr. [**Last Name (STitle) 54043**].
.
# CORONARIES: known CAD and inferior MI, no s/s of ACS now,
though new arrhythmia concerning for old scar. We continued him
on ASA 81, simvastatin 10, metoprolol tartarate was given and
uptitrated as bp and heart rate tolerated. He was sent home on
metoprolol succinate 50 mg Tablet Sustained Release daily.
.
# PUMP: Last EF 20% on [**9-/2138**] TTE. CXR without signs of edema,
does not appear overloaded on exam.
.
# UTI: Pt. reports starting treatment on [**1-1**] for UTI found
incidentally on UA at PCP's office with nitrofurantoin.
Asymptomatic throughout. Afebrile. UA was negative, and no
treatment was given while inpatient.
.
# CKD: baseline Cr 1.7 in [**7-/2138**], now elevated. Most likely [**2-18**]
pre-renal azotemia, less likely ATN given minimal down time. We
initially held home furosemide and renally dosed his meds. He
was sent home on furosemide 20 mg Tablet daily.
.
# Gout: we decreased his allopurinol to 100,to renally dose it
given CKD
.
# DM: we held his home meds and covered with ISS.
.
# Hypothyroidism: We cntinued home levothyroxine.
.
CODE: Confirmed full (though patient states "I've been saying
since I was 18 that I don't care if I die tomorrow."
.
Medications on Admission:
1. Allopurinol 300 mg daily.
2. Amitriptyline 150 mg at bedtime.
3. Diazepam 10 mg p.r.n.
4. Lasix 60 mg b.i.d.
5. Metolazone 2.5 mg three times a week (recently stopped)
6. Glipizide 10 mg b.i.d.
7. Levothyroxine 50 mcg daily.
8. Lisinopril 2.5 mg a day.
9. Metformin 1000 mg in the morning and p.r.n. in the night.
10. Metoprolol succinate 50 mg daily.
11. Omeprazole 20 mg b.i.d.
12. Simvastatin 10 mg a day.
13. Warfarin 7.5mg 3x/week (MWF), 5mg 4x/week
14. Aspirin 81 mg a day.
15. Docusate 100mg [**Hospital1 **]
16. Percocet 5/325 Q6h prn pain
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
3. diazepam 5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
4. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
15. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
Take for one week total until [**1-13**], then decrease to 200 mg
daily.
Disp:*120 Tablet(s)* Refills:*0*
17. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**1-13**].
Disp:*30 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
Please check Chem-7 and INR on Thursday [**2139-1-8**] and call
results to Dr.[**Last Name (STitle) 36023**],[**Last Name (STitle) **] [**Telephone/Fax (1) 36024**]
19. cephalexin 500 mg Capsule Sig: One (1) Capsule PO three
times a day for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Ventricular Tachycardia
Chronic Systolic Heart Failure
Ischemic Cardiomyopathy
Coronary Artery Disease
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 had a dangerous heart rhythm called ventricular tachycardia
that made you pass out. We started you on a new medicine called
amiodarone that has prevented this heart rhythm in the hospital.
An internal cardiac defibrillator was placed that will shock
your heart out of this rhythm when you are home if needed. This
will feel very strong and you should call Dr. [**Last Name (STitle) **] or [**First Name8 (NamePattern2) 16901**]
[**Last Name (NamePattern1) **] NP[**MD Number(3) 71935**] device fires or if you pass out. You will need
to take antibiotics for 2 days to prevent an infection at your
pacer site. Please talk to Dr. [**Last Name (STitle) **] about exercising with this
defibrillator in place.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
We made the following changes in your medications:\
1. Decrease the Allopurinol to 100 mg daily because of your
kidney function
2. STart Amiodarone to keep your heart in a normal safe rhythm.
Please take 2 pills twice daily for 1 week, then decrease to 1
pill per day.
3. We decreased your warfarin to 5 mg daily because the
amiodarone interacts with the warfarin and makes your PT/INR
higher. Please get your INR checked on [**2139-1-8**] with results to
Dr. [**Last Name (STitle) **] who will then tell you how much warfarin to take at
home.
4. Please try to avoid the use of Valium unless you take it at
bedtime. This may make you more prone to falls.
Followup Instructions:
Electrophysiology:
Department: CARDIAC SERVICES
When: MONDAY [**2139-1-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Primary Care:
Name: [**Hospital Ward Name 36023**],[**Hospital Ward Name **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 36024**]
Appt: [**1-13**] at 11:50am
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-4-15**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-2-18**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-6-24**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2139-1-7**]
ICD9 Codes: 5859, 2767, 4280, 4254, 4271, 4439, 2724, 412, 3572, 2749, 2449, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4609
} | Medical Text: Admission Date: [**2146-1-2**] Discharge Date: [**2146-1-4**]
Date of Birth: [**2080-12-30**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Tongue swelling
Major Surgical or Invasive Procedure:
Laryngoscopy
History of Present Illness:
65-year-old male with history of coronary artery disease,
diabetes and hypertension who presenting following discharge
[**1-1**] following burhole evacuation of subdural hemorrhage
presenting to the [**Hospital1 18**] ED with left sided tongue swelling and
dyspnea which began overnight on New Years. He was recently
discharged from [**Hospital1 18**] after a hospitalization for evacuation of
subdural hematoma. New medications on discharge include:
codeine,
Admitted [**Date range (1) 32177**] for subdural hemorrhage, was stable although
did have some nausea and vomiting, was not intervened upon and
discharged although did not follow up in clinic. Patient
represented [**12-29**] with increased confusion and right facial
droop and on [**12-30**] underwent a left frontal burr hole evacuation
of chronic SDH and discharged [**2145-12-31**] following operation. Of
note, while in house, initially, patient was not taking
lisinopril, however, this was restarted 12/27 per the orders,
although a medicine consult on [**12-30**] asked it to be restarted.
Also of note, in [**12-29**], patient was given FFP/platelet
transfusion although he had normal PT/INR and platelet levels.
He had adverse reaction to transfusion with hives/itching and
required benadryl and monitoring for airway compromise.
In the ED, initial VS were: 11:29 Temp: 97.6 HR: 102 BP:
183/115 RR: 20 97% RA. He was not stridorous or wheezing. He was
given Diphenhydramine 50mg IV, Famotidine 20mg IV, and
Methylprednisolone 125mg IV. He was seen by ENT who performed
laryngosocpy and noted a swollen glossus, and no laryngeal or
epiglotteal edema. A size 7 nasopharyngeal airway and
endotracheal intubation was deferred. Given severity of tongue
sweling and concern for the possible need for intubation, he was
admitted to the MICU for close monitoring.
Vitals on transfer were P;89 BP:163/87 rr:17 SaO2:97% RA.
On arrival to the MICU, patient is [**Last Name (un) 664**] and in no acute
distress.
Past Medical History:
Hypertension
Hyperlipidemia
ABNORMAL LIVER FUNCTION TESTS
DIABETES MELLITUS Type II
ANEMIA
CHRONIC PARANOID SCHIZOPHRENIA
CORONARY ARTERY DISEASE - angioplasty 6 years ago in NJ
EXERTIONAL DYSPNEA
EYE ALLERGY
NECROBIOSIS DIABETICORUM
R ARM PAIN
Barrett's esophagus (biopsy)
Social History:
Single, has six children (4 daughters) lives alone but stays
with daughter occasionally.
Quit tobacco 5yrs ago after 40pack yrs
- Alcohol: Patient denies currently, but does report drinking in
[**Month (only) 359**] when he fell
- Illicits: denies
Family History:
No history of heeridetary angioedema, daughter with diabetes.
Otherwise non-contributory.
Physical Exam:
Admission:
Vitals: T: 98.2 BP:165/80 P:89 R: 18 O2:98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, tongue is enlarged inferiorly with
evidence of clear fluid filled bubbles, appearing like a
jellyfish. oropharynx unable to see due to tounge enlargement,
EOMI, PERRL, surgical scar with staples over left frontal/
parietal bone. Well healed wound over right occiput.
Neck: evidence of swelling under central mandible, supple, JVP
not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,
Skin: no evidence of hives or rashes
Pertinent Results:
Admission:
[**2146-1-2**] 12:00PM BLOOD WBC-10.2 RBC-4.26* Hgb-11.9* Hct-36.1*
MCV-85 MCH-27.9 MCHC-32.9 RDW-13.4 Plt Ct-251
[**2146-1-2**] 12:00PM BLOOD Neuts-73.4* Lymphs-18.6 Monos-5.1 Eos-2.3
Baso-0.5
[**2146-1-2**] 12:00PM BLOOD PT-11.6 PTT-27.1 INR(PT)-1.1
[**2146-1-2**] 12:00PM BLOOD Glucose-234* UreaN-30* Creat-1.0 Na-137
K-4.2 Cl-99 HCO3-25 AnGap-17
[**2146-1-2**] 12:00PM BLOOD ALT-21 AST-20 AlkPhos-80 TotBili-0.3
[**2146-1-2**] 12:00PM BLOOD Albumin-4.4
[**2146-1-2**] 12:00PM BLOOD C3-PND C4-PND
[**2146-1-2**] 12:00PM BLOOD Phenyto-14.6
Brief Hospital Course:
65-year-old male with history of coronary artery disease,
diabetes and hypertension who presenting following discharge
[**1-1**] following burhole evacuation of subdural hemorrhage
presenting to the [**Hospital1 18**] ED with left sided tongue swelling and
dyspnea which began overnight on New Years.
# Angioedema with marked inferior aspect tongue swelling likely
secondary to lisinopril which patient has been taking since [**2143**]
and filled in pharmacy early [**2145-12-2**]. Also possible is
reaction to dilantin. Patient was managed with a nasal trumpet
initially and no intubation. Patient was admitted to the ICU
for airway monitoring. LFTs were normal and at time of ICU
transfer, C4, C3 were pending. We held lisinopril and started
HCTZ 25mg daily for HTN control (patient was on HCTZ in the
past, held for "hypotension"). We also stopped dilantin (level
was 14.6 and therapeutic) and switched over to keppra 750mg [**Hospital1 **]
to be continued until seen in neurosurgery clinic. We also
started methylprednisolone 125mg q8h for a day and then switched
to PO decadron 10mg q8h to continue for a total of 6 days and no
taper. We also started famotidine 20mg q12h and diphenhydramine
50mg TID in the peri-angioedema period. Within 24 hours of
arrival to the ICU, the patient's tongue inflammation reduced
considerably. Patient was initially kept NPO, but was then
transitioned to full diet without difficulty. He was then
transferred to the floor. He improved significantly with
dexamethasone therapy. His daughter confirmed that she would
throw out his lisinopril and dilantin at home and ensure he
follows up to his PCP appointment the following day.
# Recent subdural hematoma with evacuation [**2145-12-29**]: no
neurologic defecits at this time. As above, we held dilantin
given possible SJS with dilantin (maybe appearing as angioedema
in this instance) and switched to keppra 750mg [**Hospital1 **] after talking
with the neurosurgery team. We held dilantin and patient will
continue keppra until following up with neurosurgery clinic.
Patient needed staples removed either by neurosurgery as an
outpatient or in house between [**Date range (1) 32178**]/12 and was told to
schedule a follow up with them.
# Diabetes, type 2 uncontrolled - A1C 9.3, prior to previous
admission, patient on glyburide, metformin and insulin detemir.
Glyburide discontinued on discharge and decrease dose to 25U at
bedtime (approx [**2-4**] of home dose of 35U at bedtime) and started
insulin sliding scale. In the unit, patient was given insulin
sliding scale as well as glargine 20Units while NPO q24h. On the
floor he had some sugars in the 200s, occasionally 300s due to
steroids which we felt would improve after stopping steroids in
2 days. He will go to 35 Units on discharge/ when eating, which
is identical to his home dose. His PCP will continue to follow
his blood sugars.
# Hypertension - patient hypertensive at admission 183/115 and
was on lisinopril since [**2143**] (confirmed by pharmacy). We
started HCTZ as above 25mg qd with permissive hypertension to
the 150s while the patient on steroids. His PCP can follow up
his blood pressures and a chem 7.
# Schizophrenia/ psych/ neuro: We continued perphenazine 12mg PO
qhs and benztropine 2mg [**Hospital1 **]. Held alprazolam 2mg PO qhs, given
diphenhyrdamine.
Medications on Admission:
1. docusate sodium 100 mg Capsule [**Hospital1 **]
2. alprazolam 2 mg PO QHS
3. betamethasone dipropionate 0.05 % Cream Appl Topical [**Hospital1 **]
4. benztropine 2 mg [**Hospital1 **]
5. perphenazine 12 mg Tablet PO QHS
6. lisinopril 40 mg Tablet PO DAILY
7. phenytoin 125 mg/5 mL Suspension PO TID
8. simvastatin 40 mg Tablet DAILY
9. Tylenol-Codeine #3 300-30 mg 1 Tablet PO q6 hours PRN pain.
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation four times a day as needed for shortness of breath or
wheezing.
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
2. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day) for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
3. perphenazine 8 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
4. benztropine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO Q8H (every 8
hours) for 2 days.
Disp:*18 Tablet(s)* Refills:*0*
6. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
UNITS Subcutaneous at bedtime.
11. alprazolam 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) 2 PUFFS
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Angioedema
Anemia
Diabetes mellitus type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for tongue swelling called "angioedema". This was
thought to be due to lisinopril, which can happen any time while
on this medication. A much less likely possibility is a reaction
from your new seizure medication Dilantin, therefore, to be
safe, we also changed you to a different seizure medication
called Keppra. If you develop worsening swelling or difficulty
breathing, please go to the emergency room immediately. Also, we
noted your blood counts are low, you will need an endoscopy for
your Barrett's esophagus screening and a repeat colonscopy given
your polyp.
We have made the following changes to your medications:
STOP lisinopril (your daughter will throw away all your pills)
STOP dilantin (your daughter will throw away all your pills)
For seizure prevention due to your recent head injury:
START Keppra 750mg by mouth twice daily
For your angioedema:
START dexamethasone 12mg by mouth every 8 hours for two more
days (last dose [**2146-1-6**])
START benadryl 25mg by mouth three times daily for 2 more days
For your alcohol use:
START multivitamin, folate, and thiamine
Followup Instructions:
Please set up an appointment with neurosurgery within 2 weeks:
([**Telephone/Fax (1) 88**].
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2146-1-5**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: MONDAY [**2146-2-7**] at 10:00 AM
With: [**Doctor First Name 674**] BROW [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: TUESDAY [**2146-2-22**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22387**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2146-1-5**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4610
} | Medical Text: Admission Date: [**2197-12-29**] Discharge Date: [**2198-1-7**]
Date of Birth: [**2142-5-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and placement of an intra-aortic balloon
pump
History of Present Illness:
55 yoM w/ a h/o hypercholesterolemia transferred from [**Hospital 487**]
Hospital for STEMI. Patient had the onset of chest pain while
having an argument with his wife. Wife noted that he appeared
diaphoretic. The pain started after 10 pm. Just prior to the
event, patient had hit his head against the wall a number of
times in frustration. His wife called the ambulance and he was
brought to [**Hospital3 **]. In the ambulance he received SL NTG
x 3 with improvement in his pain. At [**Hospital3 **], he
complained of [**1-29**], substernal, nonradiating chest pain as if he
"pulled a muscle". ECG showed anterolateral ST elevation. He
received an additional SL NTG but became hypotensive by report.
He also received aspirin 325 mg, plavix 600mg, heparin and
integrillin bolus and drip and was transferred to [**Hospital1 18**] for
cardiac catheterization. He arrived at [**Hospital1 18**] at ~ 1am.
.
In the cath lab, cardiac catheterization revealed a proximal LAD
occlusion. IABP was placed prior to intervention and he was
started on dopamine for SBPs in the 70s. He received a BMS to
the LAD. Following intervention, he became hypoxic requiring
intubation. Following intubation, large amounts of pink frothy
sputum suctioned from ETT. Patient received 10 mg of vecuronium
and midazolam boluses to complete the case. A pulmonary
catheter was placed revealing a PCWP of ~25. ABG significant for
respiratory acidosis. He received 40 mg and then 80 mg of IV
lasix. Bedside ECHO performed revealed symmetric LVH and an
akinetic septum, anterior wall, and apex with hyperdynamic
inferoposterior walls.
.
ROS is unobtainable as the patient is intubated. Wife reveals
that patient is typically healthy. BPs are usually low with
systolics in the 100s. His only medical problem has been
elevated cholesterol for which he has not been treated. He has
otherwise never been in the hospital.
Past Medical History:
Hyperlipidemia
Social History:
Married. Lives in [**Location 7658**] with his wife. [**Name (NI) **] 2 children, one
living at home. Originally from [**Country 3992**]. Moved to US in [**2160**].
Works in real estate. Nonsmoker. Occasional EtOH. No drugs.
Family History:
Family history is significant for a CVA in his mother in her
70s. His father died at a young age but his wife is unsure of
the cause.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 94.4, BP 145/109, HR 80, RR 25, O2 99% on AC 450x25, PEEP
15, FiO2 0.6, peak pressure 34, plateau pressure 27
Gen: Intubated, sedated.
HEENT: Pinpoint pupils. Minimally reactive but symmetric.
Neck: Supple with JVP of 15 cm H2O at 30 degrees.
CV: RRR. Heart sounds difficult to auscultate due to coarse pulm
rales. No murmur, S4, S3 appreciated.
Chest: diffuse coarse rales throughout bilateral lung fields.
No HSM. No abdominial bruits.
Groin: PA catheter and arterial sheath in R groin. IABP in L
groin.
Ext: No LE edema. Bilat [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. with symmetric distal pulses
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: Pupils pinpoint but equal. Face symmetric. Moves all
extremities with lightened sedation
Pertinent Results:
ADMISSION LABS:
[**2197-12-29**] 03:30AM BLOOD WBC-23.3* RBC-5.61 Hgb-16.4 Hct-52.1*
MCV-93 MCH-29.3 MCHC-31.6 RDW-12.4 Plt Ct-273
[**2197-12-29**] 03:30AM BLOOD Neuts-91.3* Bands-0 Lymphs-5.7* Monos-2.5
Eos-0.3 Baso-0.1
[**2197-12-29**] 03:30AM BLOOD PT-13.2 PTT-129.8* INR(PT)-1.1
[**2197-12-29**] 03:30AM BLOOD Plt Smr-NORMAL Plt Ct-273
[**2197-12-29**] 03:30AM BLOOD Glucose-304* UreaN-22* Creat-1.0 Na-138
K-4.5 Cl-107 HCO3-17* AnGap-19
CARDIAC ENZYMES:
[**2197-12-29**] 03:30AM BLOOD CK(CPK)-7701*
[**2197-12-29**] 12:11PM BLOOD CK(CPK)-[**Numeric Identifier 35390**]*
[**2197-12-29**] 03:30AM BLOOD CK-MB-GREATER TH cTropnT-20.79*
[**2197-12-29**] 12:11PM BLOOD CK-MB-GREATER TH cTropnT-14.88*
[**2197-12-29**] 03:30AM BLOOD Calcium-7.2* Phos-4.4 Mg-2.0 Cholest-PND
ECG [**2197-12-28**] pre-intervention:
NSR @ 70. Nl axis and intervals. 4-[**Street Address(2) 35782**] elevation in
I,aVL, V3-[**Street Address(2) 78165**] depressions in III,aVF. QWs in
V1-3.
ECG [**2197-12-29**] post-intervention: NSR and atrial tachycardia. Nl
axis and intervals. QWs in I, aVL, V1-2. TWI in V1-4.
[**2197-12-29**] TTE:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate regional left ventricular
systolic dysfunction with akinesis of the anterior wall, septum,
distal inferior wall and apex (LAD distribution). The remaining
segments are somewhat hyperdynamic (LVEF = 35%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD.
[**2197-12-29**] Cardiac Catheterization (see report for further details):
1. Initial angiography revealed two vessel CAD. The LMCA
and LCX were angiographically normal. The RCA had 60% mid
disease. The
LAD was proximally occluded by thrombus.
2. Placement of IABP for cardiogenic shock.
3. Successful stenting of mid LAD with 3.5x18 BMS.
4. Intubation for hypoxic and ventilatory failure in setting of
flash
pulmonary edema. Patient was difficult to ventilate due to
heavy frothy
secretions and high airway plateau pressures.
5. Echo in cath lab did not reveal any mechanical complication
but with
large anterior WMA consistent with his anterior infarct.
[**2197-12-30**] CT Abd/Pelvis:
1. Effusion/atelectasis at bilateral lung bases non-optimally
evaluated given lack of IV contrast administration. Superimposed
infection may be present.
2. No retroperitoneal hematoma.
3. Nonspecific stranding surrounding the pancreas and small
amount of simple- appearing fluid within the pelvis. Mild
gallbladder wall edema.
4. No complications detected involving lines and tubes. IABP,
with balloon along thoracoabdominal aorta.
Brief Hospital Course:
(1) Myocardial Infarction
On [**2197-12-29**], Mr. [**Known lastname **] was found to have 100% occlusion of the
proximal LAD on cardiac catheterization; a bare metal stent was
placed. His course was complicated by cardiogenic shock,
requiring placement of intra-aortic balloon pump and intubation.
TTE on [**2197-12-29**] showed symmetric LVH with akinetic septum,
anterior wall, and apex; EF was 35%. His blood pressure was
supported with dopamine and vasopressin from [**12-29**] - [**1-2**]. He was
also on milrinone overnight from [**12-29**] to [**12-30**], but he became
hypotensive refractory to IVF and pressors, and the milrinone
was discontinued. He was started on aspirin, plavix, and
heparin, and received a course of integrilin immediately
following the cath. The IABP was pulled on [**2198-1-1**] without
complication. Cardiac index remained ~2.0, which he was running
on the balloon pump. He was extubated on [**2198-1-2**].
Repeat echocardiogram on [**2198-1-4**] showed an improved EF of 40 -
50% and less wall motion abnormality than prior echo. Coumadin
was discontinued as it was felt that he was no longer at risk
for an RV thrombus.
(2) GI Bleed
On [**2197-12-29**], he was noted to have bloody secretions and NG lavage
revealed coffeee ground emesis. Hct on admission was 52 and
dropped to 40 overnight both from the bleed and from
hemodilution (he was given 4+ L of NS for hypotension
overnight). The GI service was consulted and deferred scoping
at the time because they felt there was little probability of a
single, intervenable lesion. The patient was placed on an
pantoprazole ggt. By [**2197-12-30**], his bleed had decreased and Hct
stabilized; he was changed to PO protonix. He was sent home on
protonix 40 mg PO QD.
(3) Fevers/Pneumonia
Mr. [**Known lastname **] developed a fever on [**2197-12-30**] and was started empirically
on vancomycin & zosyn for a possible aspiration or
ventillator-associated pneumonia. CXR on [**2197-12-30**] showed a left
restrocardiac opacity concerning for pneumonia. He was treated
for seven days with vanco/zosyn.
He was noted to have occassional wheezing on lung exam, though
he has no prior history of asthma and is a non-smoker. He was
put on albuterol, ipratropium and fluticasone-salmeterol
inhalers.
(4) Abdominal Distension
Mr. [**Known lastname **] was noted to have abdominal distension on admission
that did not resolve with gastric decompression via NG tube.
Abdominal CT was performed on [**12-30**] and did not show any major
abnormalities to account for the distension. KUB was also
performed on [**2198-1-2**] which did not show ileus or obstruction.
When Mr. [**Known lastname **] was taken off sedation for ventillation, he was
not complaining of abdominal pain and have some relief of
distension with a more aggressive bowel regimen.
ISSUES FOR FOR FOLLOW-UP:
(1) Check INR to ensure that it has normalized. His coumadin
was discontinued once repeat echo showed improved cardiac
function, but his INR was supratherapeutic. He was discharged
with an INR of 5.1, though it was clearly trending down over the
three days prior to discharge.
(2) Cardiology follow-up for his MI.
(3) Please follow his wheezing symptoms. He was sent home with
albuterol inhaler to be used PRN and not put on any standing
medications because he had no prior symptoms of asthma/COPD.
Medications on Admission:
None
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing or shortness of
breath.
Disp:*1 inhaler* Refills:*0*
7. 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:
Anterior myocardial infarction, complicated by cardiogenic shock
Discharge Condition:
Stable-- breathing comfortably and satting in the upper 90's on
room air; hemodynamically stable; no chest pain.
Discharge Instructions:
You were admitted with a heart attack. You have been put on
several medications to help your heart as it heals and it is
important that you take all the medications on the list as they
are prescribed.
You should eat a low fat and low salt diet.
Followup Instructions:
Please call on Tuesday, [**2198-1-9**], to make an appointment to see
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in the next 7 - 10 days (phone number: ([**Telephone/Fax (1) 18528**]).
You should make an appointment to see your primary care doctor
in the next 2 - 4 weeks for follow-up on your health.
ICD9 Codes: 5789, 5070, 5849, 2875, 2851, 2724, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4611
} | Medical Text: Admission Date: [**2167-4-1**] Discharge Date: [**2167-4-16**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Right hip fracture after fall
Major Surgical or Invasive Procedure:
Open reduction, internal fixation of right femur
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 79974**] is a [**Age over 90 **] year old male with a history of atrial
fibrillation (not on coumadin or aspirin) and type 2 diabetes
who presents with right hip fracture following a fall.
.
He has had increasing falls of late. As per the family, they
have started to notice both a cognitive as well as physical
decline in the last 6 months.
.
Today he tripped and hit the front of his head (per report, he
couldn't remember when seen on the floor). There was no LOC.
He denies any prodromal sxs, no palpitations, no numb/tingling
in his extremities, no CP, abd pain, no weakness. Per witness
that saw fall, he was backing up when someone was helping him
when he fell. He denies headache or neck pain. He was seen at
[**Hospital3 4107**] where CT head and neck were negative for
fracture but x-rays showed right hip fracture. He was sent to
[**Hospital1 18**] for orthopedics evaluation.
.
In the ED, initial vitals were T 98.0 HR 62 BP 146/58 RR 16 O2
sat 100% RA. Exam was notable for right leg shortening and
external rotation with normal sensation and pulses distally.
Labs notable for Na 125, WBC 15.6, lactate 2.6. CXR showed faint
left retrocardiac opacity and hip x-ray showed oblique spiral
fracture of R trochanteric femur. The pt was seen by orthopedics
who recommended operative repair after medical stabilization.
The pt received levofloxacin 750 mg IV. Vitals prior to transfer
T 96, HR 89, BP 161/65, RR 18, 98% RA.
.
Currently, pt is in [**12-29**] pain (soreness in right hip).
According to family, not on coumadin b/c was d/c'ed when
platelets trended down, and was never restarted. Denies SOB
now, but always has cough and sputum (no change recently). Also
reportedly has a right sided facial droop from bells palsy
(thought [**1-21**] CVA in [**2125**]).
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
AFIB
NIDDM
? ITP
appendectomy
Hernia repair
CVA in [**2125**]
hernia x 25 years
Social History:
Lives alone in senior living, is independent. Smoked 1 ppd x 22
years, quit 30 years ago. No EtOH now, h/o heavy EtOH usage. No
recreational drugs.
Family History:
Mother died of MI at age 75, Father died [**1-21**] lung issues [**1-21**] war
exposure.
Physical Exam:
ADMISSION:
VS - T 96.1, BP 126/88, HR 78, RR 26, 96/RA
GENERAL - elderly man in NAD, pleasant, answers questions
appropriately, no accessory mm usage
HEENT - NC/AT, Right surgical pupil --> anisocoria, left pupil
reactive
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat anteriorly except some possible
crackles/coarse BS in LLLF, o/w good air movement, resp
unlabored, no accessory muscle use
HEART - IRREG, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, [**12-21**]+ peripheral pulses (radials,
DPs). Right leg externally rotated with shortening.
NEURO - grossly intact, right leg not tested, left leg 4-5/5
motor throughout. A+Ox3
GU: foley in place, very large hernia in scrotum.
DISCHARGE:
99.1 97.2 130/62 (104-130/50-70) 69 (66-72) 20 100%RA
24h 320+ PO / 925++ UOP
8h UOP NR due to incontinence in towel
FS 76-107
GENERAL - elderly man in NARD, A&O x 3, pleasant and conversant
with full sentences, cough decreased
HEENT - MMM, edentulous; R pupil surgical, L PRRL
NECK - supple, no JVD
LUNGS - very faint occasional wheeze at bilateral bases and
decreased BS at L base, o/w moving air well, no crackles or
rhonchi
HEART - irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
GU - enlarged inguinal-scrotal hernia soft with improving
ecchymosis also soft and NT, no erythema, no crepitus, no
fluctuance, no peristalsis palpated. Scrotal edema markedly
improved from prior.
EXTREMITIES - WWP, 1+ edema and with 2+ pedal pulses. R thigh
lateral incisions (2) intact with well-approximated
steri-strips, with e/o serous drainage at proximal edge of
distal incision. No crepitus, redness or fluctuance, but with
dependent improving ecchymosis and edema.
Pertinent Results:
ADMISSION LABS:
[**2167-4-1**] 01:45PM BLOOD WBC-15.6* RBC-4.54* Hgb-13.6* Hct-38.3*
MCV-84 MCH-29.9 MCHC-35.5* RDW-13.1 Plt Ct-231
[**2167-4-1**] 01:45PM BLOOD Neuts-92.0* Lymphs-4.5* Monos-2.8 Eos-0.4
Baso-0.4
[**2167-4-1**] 01:45PM BLOOD PT-13.9* PTT-29.9 INR(PT)-1.2*
[**2167-4-1**] 01:45PM BLOOD Glucose-135* UreaN-7 Creat-0.7 Na-125*
K-4.4 Cl-87* HCO3-24 AnGap-18
[**2167-4-1**] 01:45PM BLOOD CK(CPK)-175
[**2167-4-1**] 01:45PM BLOOD CK-MB-5 cTropnT-<0.01
[**2167-4-2**] 06:45AM BLOOD CK-MB-7 cTropnT-<0.01
[**2167-4-2**] 06:45AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.8 Mg-1.7
[**2167-4-2**] 06:45AM BLOOD %HbA1c-5.6 eAG-114
[**2167-4-1**] 05:22PM BLOOD Lactate-2.6*
[**2167-4-2**] 06:45AM BLOOD VitB12-709 Folate-4.2
[**2167-4-2**] 06:45AM BLOOD %HbA1c-5.6 eAG-114
[**2167-4-2**] 06:45AM BLOOD Osmolal-255*
[**2167-4-2**] 06:45AM BLOOD TSH-1.2
[**2167-4-2**] 06:45AM BLOOD Cortsol-22.2*
[**2167-4-2**] 06:45AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.8 Mg-1.7
- CXR:IMPRESSION: Faint left retrocardiac opacity, likely
atelectasis, but cannot
rule out aspiration or early pneumonia.
- HIP X RAY: Significantly displaced right subtrochanteric
femur fracture.
.
[**2167-4-5**] CXR: Frontal view of the chest compared to prior study
from [**2167-4-3**], demonstrates patchy airspace consolidation of
both lower lobes, increased from prior study, consistent with
pneumonia. Heart and mediastinum are otherwise within normal
limits except for calcified aortic arch. Upper lung zones are
relatively clear.
[**2167-4-6**] EKG - Atrial fibrillation. Complete right bundle-branch
block. Occasional ventricular premature beats. Q waves in leads
III and aVF with T wave inversion in those leads. Compared to
the previous tracing of [**2167-4-2**] the T wave changes in leads III,
aVF and V4-V6 are much more prominent. Otherwise, no diagnostic
interval change.
[**2167-4-8**] Scrotal ultrasound: There is a large inguinoscrotal
hernia with loops of bowel in the scrotum, markedly displacing
the right testicle cephalad and left testicle caudally and
anteriorly. The right testicle measures 4.5 x 2.8 x 1.6 cm. The
left testicle measures 3.2 x 2.7 x 1.3 cm. Assessment of
intra-testicular arterial flow is somewhat difficult secondary
to the moderate displacement by the large hernia. Venous flow is
demonstrated in both testicles, but the left testicle has
markedly diminished arterial flow.
Intermittent peristalsis is noted in the herniated bowel
loops, and intraluminal bowel gas causes "dirty" shadowing.
However, in a focal region in the left scrotum, dirty shadowing
is noted without observable peristalsis. While this non-specific
and could represent intraluminal bowel gas in a hypoactive bowel
loop, free air from perforated bowel cannot be completely
excluded.
There is no fluid collection in the scrotum to suggest
hematoma or abscess. The patient did not complain of focal
tenderness during the scan.
IMPRESSION:
1. Large hernia with loops of bowel and fat in the scrotum,
displacing the testicles.
2. Testicle size within normal limits. Relatively diminished
arterial flow in the left testicles. Arterial waveform not
clearly established.
3. No evidence of hematoma or abscess in the scrotum.
4. A focal area of "dirty" shadowing in the left scrotum,
without demonstrable peristalsis, nonspecific and could
represent a hypoactive bowel loop with intraluminal bowel gas
but cannot completely exclude free gas from bowel perforation.
Recommend clinical correlations. If clinical concern remains
high, consider CT study for further evaluation.
[**2167-4-9**] Video swallow:Barium passes freely through oropharynx
and esophagus without evidence of obstruction. There is
aspiration and penetration noted with thin liquids. Otherwise,
there is no gross aspiration or penetration noted with other
consistencies of barium. There is significant residue and slow
swallowing mechanism noted with all consistencies of barium. For
more details, please refer to the speech and swallow division
note in OMR.
[**2167-4-13**] LUE ultrasound
Grayscale, color and Doppler images were obtained of the left
IJ,
subclavian, axillary, brachial, basilic, and cephalic veins.
Normal flow,
compression, and augmentation is seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
[**2167-4-13**] CXR
Opacification of the left mid and lower lung has increased
compared
to [**2167-4-5**], and is some combination of consolidation,
atelectasis, and effusion. The right lung is clear. Lung volumes
are low, causing exaggeration of the heart size. The mediastinal
contours are normal. There is no pneumothorax. Chilaiditi's sign
is noted (air-filled colon interposed between the liver and
right hemidiaphragm). Dense calcification of the thoracic aorta
is seen. Extensive bilateral carotid calcifications are noted.
Surgical clips are seen in the right upper quadrant of the
abdomen.
IMPRESSION:
1. Increased opacification of the left mid and lower lung is a
combination of consolidation, atelectais, and effusion.
2. Extensive bilateral carotid calcifications.
[**2167-4-13**] HIP XRAY
Patient with a IM rod and gamma nail fixating a right
subtrochanteric femoral fracture with an unchanged 3mm step off
of the lateral corticated margin with stable minimal overiding.
Fracture line is still readily apparent. No clear interval
development of bony bridging. Degenerative changes are noted in
the bilateral femoroacetabular joints with joint space narrowing
and sclerotic change. Degenerative changes are also
noted in the lower lumbar spine with disc space narrowing and
endplate
sclerosis.
Patient appears to have a very large left-sided hernia, possibly
scrotal with significant amount of radiopaque density in bowels,
likley due to prior barium studies.
IMPRESSION: Right subtrochanteric femoral fracture fixated by IM
rod and
gamma nail with unchanged 13 mm lateral step off. No evidence of
hardware
complication or interval healing. Large left-sided hernia,
possibly scrotal, please correlate clinically.
DISCHARGE LABS:
- Na 125
- Cl 93
- HCO3 25
- K 4.0
- BUN 8
- Cr 0.5
- Glu 93
- Ca 7.7
- Mg 1.7
- Phos 3.5
- WBC 3.9
- Hct 30.9
- Plt 199
Brief Hospital Course:
Mr. [**Known lastname 79974**] was hospitalized with a right hip fracture following
a fall and underwent an uncomplicated right open reduction of
his internal fracture with a cephalomedullary nail. Please see
operative report for full details. In the immediate
postoperative period, he was hypoxic with altered mental status
due to difficulty protecting his airway. His hypoxia and airway
issues improved during a short stay in the ICU.
1. Right hip fracture: s/p ORIF on [**2167-4-3**] as above, had
adequate pain control with infrequent Tylenol as needed.
Incision was noted to have continuous serous oozing without
evidence of infection. A 5-day course of Ancef was given.
Patient is to continue prophylactic lovenox for 4 weeks from
[**2167-4-3**]; it was held for one day due to significant ecchymosis
and vitamin K was given to reverse INR. Ecchymosis remained
stable, showed evidence of slow resolution, and lovenox was
restarted. Please continue to monitor ecchymosis, INR, and
incision drainage (staples removed [**2167-4-15**]). Follow up is
scheduled with Orthopedics on [**2167-6-11**]. Pt will need PT for
rehab.
2. Dysphagia/dysarthria: Postop difficulty protecting airway now
improved s/p MICU stay likely [**1-21**] post-intubation swelling. Pt
has had mental decline last 6 mos and family does report a long
history of phlegm production and difficulty clearing his
secretions w/o frank episodes of aspiration or hospitalizations
for PNA. Of note, mental status declined during this
hospitalization, but improved back to baseline. Family notes
tongue swelling and some dysarthria that was worse than baseline
but is also now improved. Speech and swallow eval, video
swallow noted aspiration and penetration with thin liquids and
residue after all consistencies of barium and slow swallowing
mechanism. He was given PPN and advanced to a diet of ground
solids and nectar pre-thickened liquids as well as Magic Cup
dietary supplementation. After reevaluation by the swallow team
his liquids were advanced to thin liquids and PPN was
discontinued. He is to take small bites with multiple swallows.
Please crush all pills and administer with applesauce. Please
assist with meals and check for food pocketing in mouth. Please
administer TID oral care. Please obtain nutrition consultation
within one week of discharge to assess for nutrition needs.
3. PNA: Completed 7 day course of levaquin for PNA on CXR,
clinically remained afebrile with unchanged baseline cough and
no oxygen requirement.
4. Hernia: Inguinal hernia into scrotum that per pt and family
is 25 years old without hernia repair given asymptomatic. [**4-8**]
ultrasound showed herniated loops of bowel with an area that may
either represent hypoactive bowel with intraluminal air or
potentially perf with free air. Pt is without clinical signs of
obstruction or perforation or infection, but would have low
threshold to evaluate with CT scan if he complains of any
abdominal or hernia/scrotum pain, if hernia appears tense, or if
with any fever/white count, nausea/vomiting, or other signs of
obstruction/perforation/incarceration. Normal bowel movement
was guaiac negative on [**4-9**]. He remained with a foley for
comfort during admission, and this was discontinued on [**4-15**]; he
was able to void normally afterwards.
5. Anemia: Received a total of 3 units PRBC transfusion in the
first few days postoperatively, and hematocrit remained stable
thereafter. Blood loss was into subcutaneous space as evidenced
byt RLE ecchymoses. Hematocrit has been stable at ~30.
6. Hyponatremia: to low 120s postop, labs indicated hypovolemic
hyponatremia, which improved with normal saline hydration. He
subsequently redeveloped hyponatremia; cortisol was normal and a
renal consultation found this consistent with SIADH, likely due
to pain as he did not have any concerning medications or history
to suggest another etiology. His sodium has improved with fluid
restriction of 1500mL daily and sodium supplementations. He
will need sodium checked every other day and may stop sodium
supplementation when it is greater than 130. When the sodium is
greater than 133 he can stop the fluid restriction. Please
continue to monitor electrolytes as above.
7. Afib: Pt remained on diltiazem. He is not on home coumadin
or aspirin given history of low platelets, per family. His pills
were crushed in applesauce but it was unclear how much of his
dosage he was able to receive due to dysphagia. His blood
pressure and heart rate remained well-controlled without
additional medications. He reported some occasional
lightheadedness attributed to a combination of dehydration and
atrial fibrillation which led to his unsteadiness and the
inciting fall.
8. Non-insulin dependent diabetes: His home glipizide was held
and he remained on an insulin sliding scale. On arrival his
sugars were in the 190s, but a hemoglobin A1c was 5.6%, and his
sugars remained below 150. Eventually his fingersticks and
sliding scale insulin were stopped as he did not require insulin
for over a week. He is to STOP glipizide and continue diet
modifications on discharge. Labs are ordered to follow; please
have primary physician monitor for good postoperative blood
sugar control.
9. Edema: With fluid restriction and sodium supplementation he
developed diffuse edema. A test dose of Lasix was given and his
serum sodium remained stable. The edema improved markedly with
Lasix and he is to continue Lasix until sodium supplmentation is
stopped.
10. Incidental finding of carotid calcification on chest x-ray:
Will require outpatient follow-up with primary care provider.
Medications on Admission:
Diltiazem CD mg 180 daily
Glipizide 5 mg daily
Tylenol prn pain
Discharge Medications:
1. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: do not exceed 4000mg daily.
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 2 weeks: discontinue [**2167-5-1**].
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
8. Outpatient Lab Work
CBC, Chem 10, PT/PTT/INR every Monday Wednesday Friday to
monitor hematocrit, hyponatremia, INR. Please have primary
physician monitor these labs and determine when to discontinue
lab draws.
9. Outpatient Physical Therapy
Please evaluate for PT needs following right hip fracture repair
10. Outpatient Speech/Swallowing Therapy
Please follow up aspiration and dysphagia noted on previous
barium swallow video. Please evaluate for ability to advance
diet or need for NPO and parenteral nutrition.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
12. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day): Discontinue when serum sodium >130. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis:
Right intertrochanteric/subtrochanteric hip fracture.
Atrial fibrillation
Large inguinal hernia in scrotum
Syndrome of Inappropriate Antidiuretic Hormone
Secondary diagnosis:
Pneumonia
Dysphagia
Poor nutrition and oral intake
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair.
Discharge Instructions:
Dear Mr [**Known lastname 79974**],
You were hospitalized with a hip fracture and underwent surgery
to repair this fracture. We feel that your fall was due to
lightheadedness from your atrial fibrillation. Please have your
primary physician evaluate your [**Name9 (PRE) 19390**] atrial
fibrillation and work up potential osteoporosis leading to your
hip fracture.
You were found to have low sodium indicating dehydration, and
you were given intravenous rehydration as well as improved
nutrition. Your low sodium continued and you are now on a
fluid-restricted diet with salt replacement. You will need labs
drawn three times a week and can stop the salt replacement pills
when your sodium reaches 130. Please have your primary physician
follow up your fluid and poor nutrition status and determine
whether you need additional nutrition.
You were found to have an aspiration risk from poor swallowing
and your food was modified to help you eat safely. Please have
your rehab facility follow the diet modifications below until
further evaluation:
- PO with assist: Ground solids and thin liquids
a. alternate bites/sips
b. small bites/sips
c. intermittently check mouth for pocketing
- Medications crushed in applesauce
- TID oral care
- nectar thick oral nutritional supplements (magic cup).
You were treated for a pneumonia that we think was a result of
food aspiration. You are breathing well without oxygen.
An ultrasound demonstrated bowel in your inguinal hernia that
has extended into your scrotum. We did not feel there was
clinical evidence of perforation or obstruction as your bowel
movements were normal, non-bloody, and you were without pain.
Please have your physician closely monitor this hernia for
danger signs of pain, obstruction, incarceration, or perforation
of bowel.
You had a foley catheter to help with urinary drainage given
your decrease mobility after the operation. You were able to
urinate after it was removed.
The following changes were made to your medication regimen:
- ADDED Lovenox injections to be discontinued [**5-1**] (4 weeks
after your surgery date).
- ADDED Sodium Chloride 1g tablets three times a day, to be
discontinued when your serum sodium is >130
- ADDED Furosemide 20mg daily
- ADDED Multivitamin and Colace.
- ADDED Albuterol and Ipratropium nebulizers, continue these as
needed.
- STOPPED glipizide.
Please continue taking the rest of your medications as
prescribed.
Followup Instructions:
1. PRIMARY CARE
- Please schedule follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab. You should review your medications and
discuss follow up care for your low sodium, atrial fibrillation,
and hip surgery as well as the finding of carotid artery
calcification.
2. ORTHOPEDIC SURGERY
Department: ORTHOPEDICS
When: THURSDAY [**2167-6-11**] at 11:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2167-6-11**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2167-4-16**]
ICD9 Codes: 5070, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4612
} | Medical Text: Admission Date: [**2126-6-16**] Discharge Date: [**2126-6-19**]
Date of Birth: [**2050-7-1**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Simvastatin / Pravastatin / Cocaine / Aricept / Latex
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 year old female with recent AVR and CABG on [**2126-5-10**] presents
with fatigue, depression, N/V x1 this morning. Pt is unable to
relate history due to Alzheimer's and short term memory issues
although she can related history from one month ago, discuss
surgery and answer questions about immediate symptoms. She
states that she has been doing relatively well, "good". She
denies any CP, SOB, no N/V, no abd pain. Her daughter reports
that her mother has been refusing all food and appears
depressed. She notes that she was started on Lexapro in the past
few weeks but then switched to paxil 8 days ago by a
psychiatrist at [**Location (un) 169**]. The daughter also reports that
her mother attempted [**Name2 (NI) 2452**] juice yesterday morning, but vomited
it up. She has had no further vomiting.
.
In the ED, initial vs were 96.3 69 165/60 16 96. Pt presented
from [**Hospital3 **] with poor po intake for a few days with
increased depression. The patient reported fatigue and N/V x1
this morning but was alert, oriented and communicative, easily
able to relate history. On exam, pt was dry. She was noted to
have low K to 2.9, low Na 113. She was given got 40 meq PO K,
then D5 NS 40 KCl at 100/hr. Per nursing sign out, pt may have
vomited up PO K. 2 g Magnesium also ordered. CXR nl. EKG showed
deeping ST depression in anterior leads compared to prior, trop
neg. UA neg. Csurg was contact[**Name (NI) **] given her procedure a month
ago.
Past Medical History:
aortic stenosis s/p AVR with [**Male First Name (un) 923**] Epic Supra porcine
aortic insufficiency
coronary artery disease s/p CABG 4(LIMA to LAD, SVG to
RCA, SVG to OM, SVG to DIAG)
hypertension
hyperlipidemia
h/o Non Hodgkins Lymphoma (s/p radiation therapy)
gastroesophageal reflux
s/p splenectomy
s/p total abdominal hysterectomy
osteopenia
nonfunctioning left kidney
hypothyroidism
mild dementia
Social History:
She is divorced ([**2110**]) and lives with her daughter, spending
much time in FL. No tobacco, rare social ETOH, no illicits.
Family History:
Father deceased (59 years; CAD); Mother deceased (85 years;
Parkinsons Disease). She has 1 brother (78 years; well) and one
daughter (41 years; well).
Physical Exam:
On admission
General: Alert, oriented, no acute distress, very thin
HEENT: Sclera anicteric, MMM, slightly dry lips, no skin tenting
on forehead, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, 2/6 systolic murmur with click,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2126-6-16**] 01:00PM PLT COUNT-386
[**2126-6-16**] 01:00PM NEUTS-84.4* LYMPHS-9.1* MONOS-4.9 EOS-1.3
BASOS-0.3
[**2126-6-16**] 01:00PM WBC-10.8 RBC-4.17* HGB-12.7 HCT-35.8* MCV-86#
MCH-30.4 MCHC-35.4* RDW-15.9*
[**2126-6-16**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-6-16**] 01:00PM MAGNESIUM-1.4*
[**2126-6-16**] 01:00PM cTropnT-LESS THAN
[**2126-6-16**] 01:00PM GLUCOSE-119* UREA N-10 CREAT-1.0 SODIUM-113*
POTASSIUM-2.6* CHLORIDE-65* TOTAL CO2-36* ANION GAP-15
[**2126-6-16**] 03:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-FEW
EPI-0-2 RENAL EPI-0-2
[**2126-6-16**] 03:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2126-6-16**] 03:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-6-16**] 03:30PM URINE OSMOLAL-352
[**2126-6-16**] 03:30PM URINE HOURS-RANDOM CREAT-43 SODIUM-67
POTASSIUM-47 CHLORIDE-86
[**2126-6-16**] 08:30PM TSH-22*
[**2126-6-16**] 08:30PM ALBUMIN-4.1 URIC ACID-3.3
[**2126-6-16**] 08:30PM GLUCOSE-147* UREA N-10 CREAT-0.9 SODIUM-113*
POTASSIUM-2.9* CHLORIDE-67* TOTAL CO2-34* ANION GAP-15
[**2126-6-16**] 11:08PM URINE OSMOLAL-245
[**2126-6-16**] 11:08PM URINE OSMOLAL-245
[**2126-6-16**] 11:08PM URINE HOURS-RANDOM UREA N-209 CREAT-29
SODIUM-37 POTASSIUM-35 CHLORIDE-54
Other pertinent labs:
[**2126-6-17**] 04:05AM BLOOD Cortsol-19.6
[**2126-6-17**] 04:14AM BLOOD Lactate-1.2
MICROBIOLOGY:
- [**2126-6-16**] Wound swab - PENDING **
- [**2126-6-17**] MRSA screen - PENDING **
- [**2126-6-18**] C. difficile toxin - negative
- [**2126-6-19**] Blood culture - PENDING **
IMAGES/STUDIES:
ECG [**2126-6-16**]: Sinus rhythm. Diffuse ST-T wave changes are
non-specific, possibly secondary to left ventricular
hypertrophy. Cannot rule out ischemia. Compared to the previous
tracing of [**2126-5-12**] no change.
CXR [**2126-6-16**]: FINDINGS: PA and lateral views of the chest were
obtained. There has been interval decrease in the cardiac size.
Median sternotomy wires are identified and appear intact. The
mediastinal contour is unremarkable. There are small bilateral
pleural effusions. The lungs are clear bilaterally. No
pneumothorax is identified. There is a stable dextroscoliosis of
the thoracic spine. No acute osseous abnormalities are
identified. Multilevel degenerative changes also noted in the
spine. IMPRESSION: Small bilateral pleural effusions without
evidence of pneumonia or CHF.
ECG [**2126-6-17**]: Sinus rhythm. Prolonged Q-T interval. Left
ventricular hypertrophy with repolarization change. Compared to
the previous tracing Q-T interval has increased.
Ultrasound LLE [**2126-6-17**]: FINDINGS: Along the site of venous graft
in the left lower extremity there is a low echogenicity
elongated area. There is no evidence of fluid collection or
abnormal flow surrounding the area. Finding is consistent with
hematoma. IMPRESSION: Hematoma at the site of the venous graft
in the left lower extremity without evidence of abscess.
Brief Hospital Course:
75 year old female with recent AVR and CABG on [**2126-5-10**] presents
with fatigue, depression, N/V x1 this morning found to have
hyponatremia and hypokalemia.
.
# Hyponatremia: Na 113 on admission from a baseline of 137 one
month ago. Calculated serum osm 236. Urine sodium 67 and osm
357. Her lytes and clinical presentation are suggestive of a
mixed picture. Lack of significant altered mental status
indicates that her sodium has likely drifted down slowly over
the past month with more recent exacerbation in the past few
days with poor PO intake and N/V. Did not appear dry on iniital
exam. Per history, patient has been refusing to eat for some
time. Urine studies with urine osm over 100 were thought to be
suggestive of SIADH or hypothyroidism. Mineralactorticoid
deficiency was felt to be less likely as K was low, and am
cortisol was 19. There are also case reports of amiodarone
induced SIADH, particularly during the loading phase in the
first 3 weeks. TSH was elevated at 22. Patient was hydrated
overnight with saline in the ICU, and Na improved to 118.
Amiodarone and SSRI were held as possible contributors to SIADH.
She was transferred to the floor on hospital day #2, where PO
intake was encouraged; otherwise patient was managed
conservatively. Sodium continued to improve to 132 on the day of
discharge.
.
# Hypokalemia: Possibly secondary to vomiting vs. HCTZ (held on
arrival to the ICU). K corrected to normal with these measures.
.
# Depression: This apparently is a [**Last Name 19390**] problem with
[**Name2 (NI) 109419**] and poor PO intake described by pt and daughter one year
ago at a gerontology visit. Amiodarone may also cause malaise
and nausea, and hypothyroidism may contribute as well. As SSRI
was held as above, patient was started on Remeron. Levothyroxine
was started in place of thyroid armour. SW consult was called
to evaluate for need for further services they provided Reiki
therapy. Recommend close monitoring of patient's mood with
recent medication adjustments and consider geripsychiatry
evaluation when patient's thyroid function has stabilized.
.
# Erythema LLE: Erythema was noted at medial aspect of left knee
and pus was expressed from LLE where vein was grafted prior to
AVR/CABG. Cardiac surgery evaluated the site and recommended ID
consult and PICC placement for IV antibiotics. Patient was
started on vancomycin empirically in the ICU for possible wound
infection. Culture grew MRSA and treatment with vancomycin was
continued. Vancomycin trough was sent prior to discharge. The
rehab facility and infusion company will be notified if
vancomycin dosing needs adjusting. She will follow up in the
Infectious Disease clinic with Dr. [**Last Name (STitle) **] on Wednesday [**6-26**]
at 3:00 pm to determine specific duration of antibiotic course
and to monitor her symptoms.
.
# S/p AVR: Chest incision healing well. Seen by the cardiac
surgery team while inpatient.
.
# CAD: No CP, EKG with deepening ST changes in lateral leads
improved on repeat EKG the following day. Patient was continued
on aspirin, lisinopril, BB, statin and niacin.
.
# History of A-fib: Amiodarone appears to have been started
during last admission for CABG/AVR. EKG currently shows NSR. Per
the last discharge summary she was to discontinue amiodarone
after four weeks. The medication was discontinued on admission
and patient remained in sinus rhythm. She is scheduled to see
her outpatient cardiologist next month in clinic.
.
Code status: Full (confirmed with HCP)
Contact: Daughter [**First Name4 (NamePattern1) **] [**Name (NI) 109420**] is HCP [**Telephone/Fax (1) 109421**]
Medications on Admission:
Paxil- unkown dose
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth three times a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day
ROSUVASTATIN [CRESTOR] - 5 mg Tablet - One Tablet by mouth once
a
day
THYROID (PORK) [ARMOUR THYROID] - (Prescribed by Other Provider)
- 60 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth
B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (OTC) - Dosage
uncertain
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day as needed for prn
GINKGO BILOBA - (OTC) - 60 mg Capsule - 1 Capsule(s) by mouth
MULTIVITAMIN - (OTC) - Capsule - 1 (One) Capsule(s) by mouth
NIACIN - (OTC) - 250 mg Tablet Sustained Release - 1 (One)
Tablet(s) by mouth twice a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 1,000 mg Capsule - 2
(Two) Capsule(s) by mouth twice a day
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
2. Vancomycin 1,000 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 24H (Every 24 Hours).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Niacin 250 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
15. Outpatient Lab Work
Please have Chem 7 and CBC drawn prior on [**2126-6-27**]. The results
should be faxed to her primary care provider. [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4559**]
[**Last Name (NamePattern1) 58**] [**Telephone/Fax (1) 16236**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
PRIMARY:
- Hyponatremia
- Hypothyroidism
- Depression
- Surgical wound infection
Secondary:
- S/p aortic valve replacement and CABG
- Hypertension
- Hyperlipidemia
- Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
feeling weak for several weeks and then developing an episode of
nausea and vomiting. You were found to have a very low blood
sodium level on arrival to the hospital and you were admitted to
the medical ICU. You were also found to have impaired function
of your thyroid gland. Medications that may have contributed to
your low sodium (amiodarone and Paxil) were stopped, and you
were started on a different thyroid medication. Your sodium
level slowly improved with these measures. You were started on a
new medication called Remeron to treat your depression, as that
medication is unlikely to cause the same drop in your blood
sodium. After your sodium level began to improve, you had no
further nausea or vomiting. You were started on IV vancomycin
due to concern over a possible surgical site wound infection on
your left leg. The Infectious Disease Service was consulted and
they recommended continuing IV antibiotic treatment for
1-2weeks.
We have made the following changes to your medication regimen:
- STOP TAKING amiodarone unless/until instructed to resume by
your cardiologist
- STOP TAKING Paxil or other SSRI antidepressants unless/until
instructed to resume by your doctor
- STOP TAKING thyroid armour
- BEGIN TAKING levothyroxine to improve your thyroid function
(this may also help with energy and mood)
- BEGIN TAKING Remeron to improve your mood
- A PICC line was placed in your leg arm to facilitate
adminstration of IV antibiotics to treat your leg infection.
BEGIN TAKING Vancomycin to treat infection.
Please take all of your medications as prescribed and follow up
with your doctors as recommended below.
Followup Instructions:
Regarding surgical site infection
- Will be discharged on [**12-29**] weeks of IV vancomycin 1gm daily
with plan to follow-up in with Dr. [**Last Name (STitle) **] in [**Hospital **] clinic on
Wednesday,
[**6-26**] at 3pm, at which time will decide on need for further
antibiotics.
.
Regarding hyponatremia
- Follow-up patient's electrolytes within one week of discharge
(prior to [**2126-6-27**]). The results should be faxed to her primary
care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**] at [**Telephone/Fax (1) 16236**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 2761, 2768, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4613
} | Medical Text: Admission Date: [**2195-7-15**] Discharge Date: [**2195-7-24**]
Date of Birth: [**2126-12-3**] Sex: M
Service: SURGERY
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Complicated ventral incisional recurrent hernia.
Major Surgical or Invasive Procedure:
[**2195-7-15**]: Exploratory laparotomy, extensive lysis of adhesions,
small bowel resection and enteroenterostomy, component
separation, and ventral hernia repair
History of Present Illness:
Patient is a 68 y/o very pleasant gentleman with a symptomatic
ventral bulge. This was after a previous repair with mesh.
Imaging showed a complicated hernia with diastasis. Combined
surgery with plastics with a component separation was planned.
Past Medical History:
Past Medical History:
1.HCV
bx [**2192**]: grade 2 inflamm, stage 4 fibrosis; type 1B;
2.Peripheral neuropathy
3.Hypertension
4.History of sigmoid colon cancer
- s/p sigmoid colectomy and no further rx [**2185**]
5. Osteoarthritis
Past Surgical History:
1. Sigmoid colectomy [**2185**]
2. Cholecystectomy [**2179**]
3. Multiple incisional ventral hernia repairs
4. bilateral inguinal hernia repair on [**1-19**] and [**2-20**]
5. lysis of adhesions for SBO and Tru-Cut liver biopsy [**10-20**]
Social History:
domestic partner, [**Name (NI) **] [**Name (NI) **]. He used to live in [**Location (un) 10054**] and developed programs for patients with HIV. He is
currently a writer. He does not smoke cigarettes and does not
drink any alcohol. Former smoker, 25 py, quit 30 yrs ago. He
does [**Doctor First Name **] [**Doctor First Name **] every day and has done so
for the last 25 years.
Family History:
Lung cancer and his father who died, a brother died of diabetes,
his mother has cardiac problems and her older age, GF NHL
Physical Exam:
On Discharge:
VS: 98.2, 89, 120/76, 18, 96% RA
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: Midline abdominal incision with occlusive dressing c/d/i.
JP drains x 2 to bulb suction.
Pertinent Results:
[**2195-7-15**] 09:20PM SODIUM-138 POTASSIUM-4.0 CHLORIDE-101
[**2195-7-15**] 09:20PM MAGNESIUM-1.6
[**2195-7-15**] 09:20PM HCT-28.6*
[**2195-7-14**] 12:10PM GLUCOSE-93 UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2195-7-14**] 12:10PM estGFR-Using this
[**2195-7-14**] 12:10PM ALT(SGPT)-36 AST(SGOT)-44* LD(LDH)-196 ALK
PHOS-104 TOT BILI-1.0
[**2195-7-14**] 12:10PM TOT PROT-7.8 ALBUMIN-4.6 GLOBULIN-3.2
[**2195-7-14**] 12:10PM HCT-34.1*
[**2195-7-14**] 12:10PM PLT COUNT-211
[**2195-7-14**] 12:10PM PT-14.3* PTT-30.9 INR(PT)-1.2*
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2195-7-15**], the
patient underwent exploratory laparotomy, extensive lysis of
adhesions, small bowel resection x2 and enteroenterostomy, which
went well without complication (reader referred to the Operative
Note for details). In the PACU, recovery was complicated by
altered mental status and agitation. Patient was transferred in
ICU for observation and treatment. Patient was NPO with an NG
tube, on IV fluids and antibiotics, with a foley catheter and a
JP x 2 drains in place, and Morphine IV for pain control. In ICU
patient was stabilized to his baseline and was transferred to
the floor to continue recovery. The patient was hemodynamically
stable.
.
Post-operative pain was initially well controlled with Morphine
IV, which was converted Morphine PCA. Patient has a history of
chronic pain and he use multiple opioids at home to control his
pain. During on Morphine PCA patient pain was continue to be
high, chronic pain service was consulted and their
recommendations were implemented with good result. When patient
tolerated PO, he was converted to oral pain medication, he was
started on home regiment with Oxycodone IR for breakthrough
pain. Patient was consulted by nutritionist and was started on
TPN on POD # 5 for nutritional support. The NG tube was
discontinued on POD# 7, and the patient was started on sips of
clears on POD# 8. Diet was progressively advanced as tolerated
to a regular diet by POD# 9. The foley catheter was discontinued
at midnight of POD# 4. The patient subsequently voided without
problem.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Amlodipine 5', Clonidine 0.2''', Marinol 10'' prn for pain,
lisinopril 40', ritalin 10''', zofran 8''', oxycontin SR 20, 20,
40, protonix 40', trazodone 75 qhs, effexor 75', colace,
magnesium, milk thistle
Discharge Medications:
1. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for nausea.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO HS (at bedtime).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 15 days.
Disp:*60 Tablet(s)* Refills:*0*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Complicated ventral incisional recurrent hernia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**6-22**] 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2195-8-3**] 9:00
.
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2195-8-5**]
11:00
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2195-8-25**] 11:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2195-8-10**] 9:45
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD ([**Street Address(2) 10055**].
[**Location (un) **] [**2195-7-30**] 11:30
Completed by:[**2195-7-24**]
ICD9 Codes: 4019, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4614
} | Medical Text: Admission Date: [**2170-6-13**] Discharge Date: [**2170-7-1**]
Date of Birth: [**2100-10-1**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Transferred for cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
white male who was transferred from [**Hospital **] Hospital for
cardiac catheterization. He had been sent to the hospital by
his cardiologist to whom it had gone for two syncopal
episodes. He was transferred to an outside hospital where he
was ruled out for a myocardial infarction. He has a history
of worsening cardiac function over the last year.
One year prior to admission, he had an episode of difficulty
in talking which was possibly a transient ischemic attack.
He had a stroke workup which involved an echocardiogram
showing ejection fraction of 50% with mild aortic stenosis
and mild mitral regurgitation. He is now transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Congestive heart failure with recent echocardiogram
showing ejection fraction of 25%, mild aortic stenosis,
moderate mitral regurgitation and tricuspid regurgitation,
mild pulmonary hypertension, dilated severe global left
ventricular hypokinesis.
2. Noninsulin dependent diabetes mellitus.
3. Hypertension.
4. Right knee arthritis.
5. Transient ischemic attacks, possible small vessel disease
on magnetic resonance scan.
6. Polio as a child with no long term side effects.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin Enteric Coated 325 mg q.d.
2. Toprol XL 12.5 mg q.d.
3. Lisinopril 10 mg p.o. q.d.
4. Glipizide 5 mg q.d.
5. Simvastatin unknown dose.
6. Lasix 40 mg q.d.
HOSPITAL COURSE: The patient was admitted to the Medical
service for cardiac catheterization. He was in stable
condition. He underwent cardiac catheterization on [**2170-6-14**],
which showed severe three vessel disease. Cardiothoracic
surgery consultation was obtained at this point. He was
started on Heparin drip. Prior to surgery, he had a carotid
ultrasound study which showed less than 40% stenosis in the
left internal carotid artery.
On [**2170-6-18**], he underwent a coronary artery bypass graft
times four with left internal mammary artery to left anterior
descending, RSVG segmental to diagonal, RSVG to right
coronary artery to posterolateral. His intraoperative course
was uneventful, and he was transferred to the CSRU in stable
condition. He was extubated overnight.
He was noted to have some episodes of confusion and language
difficulty. The possibility of transient ischemic attack was
raised and a neurology consultation was obtained on
postoperative day one. They recommended a CT scan and a
magnetic resonance scan. CT scan was done and showed no
acute hemorrhage.
Recommendations were made to keep the systolic blood pressure
about 130 to 140. It was noted subsequently that when the
patient's systolic blood pressure was below 130, he would be
symptomatic with language difficulties and a seizure. He
underwent a magnetic resonance scan on [**2170-6-21**], which showed
a small area of restricted diffusion in the right prefrontal
subcortical area and also showed right internal carotid
artery and left middle cerebral artery narrowing with
significant intracranial disease. Per neurology
recommendations, he was started on Coumadin and Aspirin.
Over the next few days, he continued to have episodes of
transient ischemic attacks. His electroencephalogram was
negative at this point. He continued to be on a
Neo-Synephrine drip to his blood pressure about 130s to
prevent transient ischemic attacks. He was hemodynamically
stable with the only issue being the transient ischemic
attacks at this point.
Because of his continuing condition, it was decided to
surgically intervene at this point. On [**2170-6-26**], he
underwent a cerebral angiography with stenting of the right
internal carotid artery stenosis using two stents. He was
neurologically stable postoperatively and continued on his
Heparin drip.
Subsequently, he was deemed ready for transfer to the regular
floor. Per neurology recommendations, he was continued on
Aspirin and Plavix and will continue on it for some time in
the future. He was transferred to the regular floor on
[**2170-6-29**], in stable condition. Currently, he is able to
ambulate well. His pain is under control with p.o.
analgesics. He is now ready for discharge home.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg q.d.
2. Potassium Chloride 20 mEq q.d.
3. Colace 100 mg b.i.d.
4. Aspirin Enteric Coated 325 mg q.d.
5. Plavix 75 mg q.d.
6. Amiodarone 400 mg q.d.
7. Glipizide 5 mg q.d.
8. Lisinopril 5 mg q.d.
9. Percocet one to two tablets q4-6hours p.r.n.
FO[**Last Name (STitle) **]P: Dr. [**Last Name (Prefixes) **] in clinic in four weeks,
follow-up with primary care physician in two weeks, and with
neurology in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2170-6-30**] 23:05
T: [**2170-7-3**] 20:23
JOB#: [**Job Number 42553**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4615
} | Medical Text: Admission Date: [**2181-9-8**] Discharge Date: [**2181-9-25**]
Date of Birth: [**2117-12-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
cardiogenic shock s/p STEMI, cardiac arrest
Major Surgical or Invasive Procedure:
TandemHeart placement
Intubation
History of Present Illness:
63yo male transferred from OSH intubated s/p VF/VT arrest. Pt
was admitted through the OSH ED accompanied by friend with whom
he had been drinking heavily. He was s/p fall and had
facial/body lacerations. Pt moving all limbs and
alert/responsive on physical exam. Vitals on ED intake: T98.1
HR68 BP130/94 RR20 SatO2 100/RA. He was also c/o severe [**9-21**]
chest pain that was described "like my GERD". He was given nitro
w/o effect and GI regimen. Pt coded at 0950 went into VF/VT
arrest and defibrillated. He became bradycardic and was paced
for 2-3min before resuming NSR. Beside TTE showed anterior
hypokinesis and large LV thrombus. He was given Heparin 5300u,
ASA, ativan, fentanyl, atropine, and amiodarone 150mg bolus. Pt
became hypotensive, paced, no defib and started on Dopamine
drip. He was intubated w/o complication and airlifted to [**Hospital1 18**]
for further management. In flight began cooling with fluids.
Labs on transfer: K=3.5, Bun:Cr 17:0.8, WBC =13, Hct=47,
Plt=193, Ptt=23, INR=0.9, EtOH=146. LFT, lipase wnl. No ABGs.
.
Pt admitted directly to cardiac cath lab, intubated, and
unsedated. He was femoral cath'd and stent was placed in the
proximal LAD. He went into vfib multiple times (>8), underwent
CPR, defibrillation. He was started on max pressors: levophed
and dopamine. IABP was placed. He was given amiodarone and
started on amio drip, bicarb, epinephrine, lidocaine and
potassium. OGT was placed. Subclavian line placed. Given Heparin
4000u. Tandem heart placed and pressors were withdrawn with good
BP response. Good UO to IV lasix given in lab. Pt was sedated
and paralyzed. Begin arctic sun cooling in cath lab.
Labs in cath: multiple ABGs showed lactic acidosis likely [**2-13**]
lack of perfusion during episodes of vfib. Respiratory acidosis
corrected on vent settings VT = 550, RR=20. ABG s/p placement
tandem heart showed increase in pO2 52->275.
.
On the floor pt continued on TandemHeart and Arctic Sun cooling.
Hemodynamics monitored. Pt with hypokalemia, hypocalcemia
requiring sliding scale repletion.
Past Medical History:
Anxiety attacks
GERD
SEIZURES
HTN
.
Social History:
Married, wife [**Name (NI) **].
-[**Name2 (NI) 1139**] history: unknown
-ETOH: recent heavy use
-Illicit drugs: unknown
Family History:
pt unable to provide
Physical Exam:
Exam on Admission
GENERAL: Caucasian male, intubated and sedated, arctic sun
cooling pads in place
HEENT: multiple abrasions over face; PERRL
NECK: cervical collar
CARDIAC: no S1/S2 (TandemHeart), sounds obscured by vent
LUNGS: ventilated; upper anterior lungs auscultated only given
arctic sun pad; clear to auscultation
ABDOMEN: unable to assess given pads
EXTREMITIES: R thumb displaced and pale, cool extremities, cap
refill 2sec, +L femoral line; +R femoral TandemHeart catheter
SKIN: multiple abrasions on face, chest, extremities/hands
PULSES: no pulses palpated
.
Exam on day of Discharge:
Temp Max: 99.0 Temp current: 97.8 HR: 75-77 RR: 18-20 BP:
113-118/55-62 O2 Sat: 100% RA
24 hour I= 320 O= 1745
8 hour I= 360 O=
Weight: none
FS: none
Tele: 70's SR, no VEA
Gen: A/O x3, appears nervous, conversant, making jokes.
HEENT: supple, no JVD
CV: RRR, 2/6 systolic murmur at left upper sternal border, no
radiation.
RESP: CTAB post
ABD: soft, pos BS, BM today
EXTR: no edema. [**Month (only) **] sensation in plantar aspect of right foot
from arch to toes, also in left hand from palm to fingers with
some tingling. Right thumb with mild swelling and bruising, good
ROM, now has splint. Right groin site without ecchymosis or
hematoma.
NEURO: Alert, oriented. Using walker to ambulate.
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Skin: rash right lower back almost gone, no open areas.
Access: Midline.
Tubes: none
Pertinent Results:
[**2181-9-8**] 03:41PM BLOOD WBC-19.9* RBC-4.98 Hgb-14.9 Hct-43.4
MCV-87 MCH-29.8 MCHC-34.2 RDW-13.7 Plt Ct-224
[**2181-9-8**] 11:12PM BLOOD WBC-21.5* RBC-4.95 Hgb-15.0 Hct-42.6
MCV-86 MCH-30.3 MCHC-35.3* RDW-13.8 Plt Ct-196
[**2181-9-9**] 02:28AM BLOOD WBC-17.5* RBC-4.58* Hgb-13.9* Hct-39.2*
MCV-86 MCH-30.4 MCHC-35.6* RDW-13.9 Plt Ct-157
[**2181-9-9**] 06:07AM BLOOD WBC-15.6* RBC-4.33* Hgb-13.0* Hct-36.9*
MCV-85 MCH-30.0 MCHC-35.1* RDW-13.9 Plt Ct-135*
[**2181-9-9**] 09:53AM BLOOD WBC-17.6* RBC-4.35* Hgb-12.9* Hct-38.4*
MCV-88 MCH-29.5 MCHC-33.5 RDW-13.7 Plt Ct-175
[**2181-9-9**] 08:25PM BLOOD WBC-19.2* RBC-3.93* Hgb-11.9* Hct-33.9*
MCV-86 MCH-30.2 MCHC-35.1* RDW-14.1 Plt Ct-144*
[**2181-9-10**] 12:54AM BLOOD WBC-19.7* RBC-3.83* Hgb-11.5* Hct-33.1*
MCV-86 MCH-30.0 MCHC-34.8 RDW-14.0 Plt Ct-119*
[**2181-9-10**] 03:55AM BLOOD WBC-18.9* RBC-3.59* Hgb-11.0* Hct-30.8*
MCV-86 MCH-30.6 MCHC-35.7* RDW-14.1 Plt Ct-108*
[**2181-9-10**] 07:39AM BLOOD WBC-18.3* RBC-3.75* Hgb-11.3* Hct-32.5*
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.1 Plt Ct-116*
[**2181-9-10**] 07:56PM BLOOD WBC-12.7* RBC-3.47* Hgb-10.1* Hct-30.4*
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.8 Plt Ct-104*
[**2181-9-11**] 03:58AM BLOOD WBC-12.2* RBC-3.36* Hgb-10.1* Hct-29.0*
MCV-86 MCH-29.9 MCHC-34.7 RDW-14.9 Plt Ct-98*
[**2181-9-11**] 12:51PM BLOOD WBC-13.6* RBC-3.34* Hgb-10.0* Hct-29.5*
MCV-88 MCH-29.9 MCHC-33.9 RDW-14.7 Plt Ct-108*
[**2181-9-11**] 08:12PM BLOOD WBC-12.0* RBC-3.17* Hgb-9.5* Hct-27.5*
MCV-87 MCH-30.0 MCHC-34.6 RDW-14.7 Plt Ct-111*
[**2181-9-12**] 04:12AM BLOOD WBC-13.2* RBC-3.23* Hgb-9.8* Hct-27.9*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.7 Plt Ct-114*
.
[**2181-9-8**] 03:41PM BLOOD PT-17.1* PTT-150* INR(PT)-1.5*
[**2181-9-9**] 02:28AM BLOOD PT-13.6* PTT->150* INR(PT)-1.2*
[**2181-9-9**] 09:53AM BLOOD PT-12.7 PTT-85.4* INR(PT)-1.1
[**2181-9-9**] 04:49PM BLOOD PT-13.0 PTT-90.5* INR(PT)-1.1
[**2181-9-10**] 04:23PM BLOOD PT-12.9 PTT-73.1* INR(PT)-1.1
[**2181-9-11**] 03:58AM BLOOD PT-12.3 PTT-31.5 INR(PT)-1.0
[**2181-9-11**] 12:51PM BLOOD PT-12.9 PTT-43.7* INR(PT)-1.1
[**2181-9-11**] 08:12PM BLOOD PT-13.0 PTT-68.3* INR(PT)-1.1
[**2181-9-12**] 04:12AM BLOOD PT-13.2 PTT-67.5* INR(PT)-1.1
.
[**2181-9-8**] 03:41PM BLOOD Glucose-259* UreaN-19 Creat-1.1 Na-141
K-4.1 Cl-108 HCO3-17* AnGap-20
[**2181-9-8**] 10:00PM BLOOD Glucose-165* UreaN-17 Creat-1.0 Na-146*
K-3.0* Cl-112* HCO3-21* AnGap-16
[**2181-9-9**] 02:28AM BLOOD Glucose-176* UreaN-18 Creat-0.9 Na-138
K-4.0 Cl-110* HCO3-19* AnGap-13
[**2181-9-9**] 06:07AM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-143
K-4.3 Cl-115* HCO3-21* AnGap-11
[**2181-9-9**] 09:53AM BLOOD Glucose-110* UreaN-17 Creat-0.5 Na-146*
K-4.3 Cl-114* HCO3-23 AnGap-13
[**2181-9-9**] 01:00PM BLOOD Glucose-176* UreaN-16 Creat-0.8 Na-141
K-4.4 Cl-111* HCO3-24 AnGap-10
[**2181-9-9**] 04:49PM BLOOD Glucose-139* UreaN-17 Creat-0.8 Na-143
K-4.3 Cl-113* HCO3-22 AnGap-12
[**2181-9-10**] 04:23PM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-144
K-4.0 Cl-113* HCO3-26 AnGap-9
[**2181-9-10**] 07:56PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-142
K-4.1 Cl-114* HCO3-22 AnGap-10
[**2181-9-10**] 07:56PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-142
K-4.1 Cl-114* HCO3-22 AnGap-10
[**2181-9-11**] 03:58AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-142
K-3.7 Cl-112* HCO3-24 AnGap-10
[**2181-9-11**] 12:51PM BLOOD Glucose-103* UreaN-21* Creat-1.0 Na-144
K-3.8 Cl-112* HCO3-28 AnGap-8
[**2181-9-12**] 04:12AM BLOOD Glucose-121* UreaN-24* Creat-0.5 Na-148*
K-4.1 Cl-114* HCO3-25 AnGap-13
.
[**2181-9-8**] 03:41PM BLOOD CK(CPK)-746*
[**2181-9-8**] 10:00PM BLOOD ALT-535* AST-755* LD(LDH)-1067*
AlkPhos-62
[**2181-9-10**] 12:54AM BLOOD LD(LDH)-1181*
[**2181-9-10**] 03:55AM BLOOD ALT-315* AST-377* LD(LDH)-1122*
AlkPhos-49
[**2181-9-11**] 03:58AM BLOOD ALT-225* AST-308* LD(LDH)-1093*
AlkPhos-45
[**2181-9-12**] 04:12AM BLOOD ALT-164* AST-190* LD(LDH)-893*
AlkPhos-35*
[**2181-9-8**] 03:41PM BLOOD CK-MB-51* MB Indx-6.8* cTropnT-0.91*
[**2181-9-9**] 06:07AM BLOOD CK-MB-495* MB Indx-37.0* cTropnT-3.51*
[**2181-9-9**] 09:53AM BLOOD CK-MB-GREATER TH cTropnT-4.65*
.
[**2181-9-8**] 03:41PM BLOOD Calcium-6.3* Phos-1.7* Mg-1.9
[**2181-9-9**] 02:28AM BLOOD Calcium-7.6* Phos-1.1* Mg-2.8*
[**2181-9-9**] 09:53AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.2 Cholest-146
[**2181-9-10**] 07:39AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.8
[**2181-9-12**] 04:12AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.2
.
[**2181-9-9**] 09:53AM BLOOD Triglyc-93 HDL-51 CHOL/HD-2.9 LDLcalc-76
.
[**2181-9-8**] 11:45AM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-67* pCO2-55* pH-7.13* calTCO2-19* Base XS--11
AADO2-616 REQ O2-97 -ASSIST/CON Intubat-INTUBATED
[**2181-9-8**] 12:03PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
pO2-65* pCO2-47* pH-7.40 calTCO2-30 Base XS-2 -ASSIST/CON
Intubat-INTUBATED
[**2181-9-8**] 12:20PM BLOOD Type-ART Rates-20/ Tidal V-550 PEEP-12
pO2-87 pCO2-46* pH-7.16* calTCO2-17* Base XS--12
Intubat-INTUBATED
[**2181-9-8**] 12:42PM BLOOD Type-ART pO2-52* pCO2-58* pH-7.13*
calTCO2-20* Base XS--10
[**2181-9-8**] 01:07PM BLOOD Type-ART Rates-20/ Tidal V-550 PEEP-7
FiO2-100 pO2-275* pCO2-43 pH-7.20* calTCO2-18* Base XS--10
AADO2-420 REQ O2-70 -ASSIST/CON Intubat-INTUBATED
.
[**2181-9-8**] 04:34PM BLOOD Type-ART Temp-34 pO2-274* pCO2-29*
pH-7.33* calTCO2-16* Base XS--9 Intubat-INTUBATED
Vent-CONTROLLED
[**2181-9-8**] 05:46PM BLOOD Type-ART Temp-34 pO2-80* pCO2-32* pH-7.36
calTCO2-19* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED
[**2181-9-8**] 11:25PM BLOOD Type-ART pO2-113* pCO2-31* pH-7.40
calTCO2-20* Base XS--3
[**2181-9-9**] 01:05AM BLOOD Type-ART Temp-33.8 Rates-24/ Tidal V-500
PEEP-12 FiO2-50 pO2-123* pCO2-28* pH-7.44 calTCO2-20* Base XS--3
Intubat-INTUBATED
.
[**2181-9-8**] 11:45AM BLOOD Lactate-7.1*
[**2181-9-8**] 12:03PM BLOOD Glucose-213* Lactate-6.6* Na-140 K-2.7*
Cl-100
[**2181-9-8**] 12:20PM BLOOD Glucose-305* Lactate-8.0* Na-142 K-2.3*
Cl-106
[**2181-9-8**] 12:42PM BLOOD Glucose-272* Lactate-7.8* Na-133* K-2.5*
Cl-98*
[**2181-9-8**] 01:07PM BLOOD K-3.2*
[**2181-9-8**] 04:34PM BLOOD Glucose-206* Lactate-7.3* K-3.8
[**2181-9-8**] 05:46PM BLOOD Glucose-182* Lactate-6.2* K-3.2*
[**2181-9-8**] 08:29PM BLOOD Lactate-2.1*
[**2181-9-8**] 11:25PM BLOOD Glucose-166* Lactate-3.7* K-3.2*
.
ECG Study Date of [**2181-9-8**] 10:43:50 PM
Sinus rhythm followed by ectopic ventricular beats and possible
accelerated idioventricular rhythm with retrograde atrial
activation. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 0 130 426/464 0 -85 90
.
Cardiac Cath Study Date of [**2181-9-8**]
COMMENTS:
1. Selective coronary angiography in this right-dominant system
demonstrated one-vessel disease. The LAD had a proximal
thrombotic
occlusion and a 70% stenosis in its middle segment. The RCA and
LCX had
mild disease.
2. Limited resting hemodynamics revealed an LA pressure of 60 mm
Hg and
systemic hypotension in the setting of maximal pressor supoport.
3. Emergent successful PTCA/stent of the LAD subtotal occlusion
in
cardiogenic shock with a MINI VISION Rx 2.5x23mm bare-metal
stent (BMS).
Final angiography had showed adequate result with improved
coronary flow
and no angiographically apparent dissecton. An 8Fr 40cc IABP
advanced
into position via R femoral artery with dual chamber pacing
support via
L femoral vein. Despite these interventions, patient continued
to remain
hemodynamically unstable. TandemHeart was prepared and primed
per
protocols. A left atrial cannula via R femoral vein advanced
into
position (at 52 cm) and a 17 Fr arterial cannula advanced into
position
via left femoral artery (at transition). TandemHeart left atrial
to
femoral artery extracorporeal circuit completed for percutaneous
ventricular assist device support with hemodynamics improved but
still
guarded prognosis after multiple v-fib arrest requiring CPR and
shocks
(15-20 defibrillations). (see PTCA comments for details).
FINAL DIAGNOSIS:
1. One-vessel coronary disease.
2. Cardiogenic shock.
3. Successful PTCA/stenting of the LAD subtotal occlusion with a
MINI
VISION Rx 2.5x23mm bare-metal stent (BMS). Patient in
cardiogenic shock
not improved with R 8Fr IABP support and dual chamber pacing.
TandemHeart prepared per protocols. A left atrial cannula
advanced via R
femoral vein (at 52 cm) after successful transseptal puncture
completed
and a 17 Fr arterial cannula (placed at transition) advanced via
L
femoral artery access. This completed the TandemHeart left
atrial to
femoral artery extracorporeal circuit for percutaneous
ventricular
assist device support. (see PTCA comments for details)
4. ASA indefinitely, clopidogrel 75 mg daily
5. Vasopressin and dopamine vasopressor support
6. Serial ECG and cardiac isoenzymes
7. Echocardiogram in AM
8. Guarded prognosis
.
THUMB (AP & LATERAL) RIGHT PORT Study Date of [**2181-9-8**] 5:53 PM
FINDINGS: No previous images. There is a fracture of the volar
aspect of the base of the distal phalanx of the thumb with
substantial dorsal dislocation.
.
FINGER(S),2+VIEWS RIGHT PORT Study Date of [**2181-9-9**]
FINDINGS: Frontal and oblique views show relocation of the
previous
dislocation. A lateral view is suggested to determine whether
the lucency on the palmar surface of the distal phalanx seen on
the previous examination represents a true fracture.
.
Portable TTE (Complete) Done [**2181-9-10**] at 11:38:50 AM
Conclusions
The left atrium and right atrium are normal in cavity size. A
catheter is seen crossing the right atrium and entering the
mid-left atrium. Left ventricular wall thicknesses and cavity
size are normal. There is moderate to severe regional left
ventricular systolic dysfunction with near akinesis of the
distal 2/3rds of the anterior septum, and anterior walls, and
distal inferior wall and apex. The remaining segments contract
normally (LVEF = 25-30 %). There was minimal/no change in the
dysfunctional segments with decrease in tandem heart support
level, but the normal segments become more dynamic No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic valve leaflets are mildly thickened (?#). The
leaflets appear to open. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The severity does not change with decrease in
tandem heart support. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD.
CLINICAL IMPLICATIONS:
Based on [**2178**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Cardiac Cath Study Date of [**2181-9-11**]
FINAL DIAGNOSIS:
1. Successful removal of tandem heart cannulas with perclose to
arterial
sites, and manual pressure to venous sites.
2. This patient will receive IV antibiotic therapy.
3. Heparin is to be resumed in 6 hours.
.
Portable TTE (Complete) Done [**2181-9-20**] at 12:31:12 PM
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (ejection
fraction 40 percent) secondary to extensive apical hypokinesis.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2181-9-10**], the left ventricular ejection fraction is
increased.
.
MRA BRAIN W/O CONTRAST Study Date of [**2181-9-23**] 4:38 PM
FINDINGS: There is no intracranial hemorrhage or acute infarct.
The small
low-density areas seen on the CT correspond to multiple tiny CSF
spaces in the subcortical and deep white matter of left
posterior parietal lobe. Appearances are consistent with Virchow
[**Doctor First Name **] spaces. There are multiple small foci of T2 and FLAIR
hyperintensities in the subcortical white matter of both
cerebral hemispheres in keeping with chric microangiopathic
small vessel disease. The diffusion imaging shows no restricted
areas to suggest infarction. The ventricle dimensions and sulcal
configuration are within normal limits. There is no intracranial
mass, mass effect or midline shift. The visualized paranasal
sinuses and orbits show no abnormality.
MRA: There are no flow-limiting stenosis, vascular occlusions,
aneurysms in this non-contrast MRA study. Both ACA, MCA, PCA,
AICA and PICA are
visualized. The anterior communicating and right posterior
communicating
arteries are visualized. The left posterior communicating artery
is poorly
visualized.
IMPRESSION:
1. Multiple small CSF spaces in the left posterior parietal lobe
suggestive of prominent Virchow [**Doctor First Name **] spaces. Recommend
attention on follow up imaging.
2. Multiple subcortical T2 and FLAIR hyperintensities in keeping
with chric microangiopathic small vessel disease.
3. No acute infarct or intracranial hemorrhage.
.
ECG Study Date of [**2181-9-24**] 8:52:34 AM
The rhythm is probably sinus but consider also ectopic atrial
rhythm. Anterior wall myocardial infarction of indeterminate age
but may be acute/recent/in evolution. The QTc interval appears
prolonged but is difficult to measure. Since the previous
tracing of [**2181-9-23**] there is no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 150 100 482/489 -2 61 98
.
Brief Hospital Course:
Mr. [**Known lastname **] is a 63yo male with GERD, anxiety attacks who was
admitted to OSH s/p fall, EtOH binge, and complaints of chest
pain. Patient was transferred from OSH intubated and on
pressors for VT/VF arrest [**9-8**] am. He was taken directly to the
cath lab for stent to proximal LAD, TandemHeart placement, and
Arctic Sun cooling protocol for cardiac arrest s/p STEMI and
cardiogenic shock.
.
s/p STEMI:
Patient presented to OSH with STEMI and had confirmed elevated
cardiac biomarkers. Cardiac history was unknown. S/p BMS placed
in prox LAD in cath lab here [**9-8**]. He was started on Heparin
gtt, clopidogrel 600mg loading dose, and then 75mg daily. He was
cooled per Arctic Sun protocol for neuroprotection. There was
some question of possible LV thrombus on TTE at outside
hospital, though TTE here on [**9-10**] showed no signs of thrombus.
Patient was continued on heparin drip throughout CCU course in
setting of akinetic apex and risk for LV thrombus formation; he
was transitioned to warfarin. He was bridged appropriately and
his INR was therapeutic on discharge.
.
Cardiogenic shock:
Pt s/p large STEMI confirmed anterior hypokinesis and LV
thrombus on OSH bedside TTE, LVEF 20%. Pt was airlifted from OSH
and taken immediately to cardiac catheterization, BMS placed in
prox LAD. He had multiple runs of Vfib at both facilities, s/p
CPR, defibrillation and pressor support. Pt placed on
TandemHeart in cath lab with improvement of oxygenation and
urine output. Patient had been started on dopamine, vasopressin,
and levophed in the cath lab; the levophed was quickly weaned
off prior to transfer to the CCU. He was continued on pressor
support on arrival to the CCU and weaned off vasopressin
overnight. He was also started on Arctic Sun protocol s/p
arrest.
On [**9-11**], Tandemheart catheter was noted to have shifted
slightly from left atrium into right atrium with no significant
change in oxygenation. Flow rate on percutaneous LVAD was
turned down, which patient appeared to tolerate well, so patient
was taken to cath lab for removal of Tandemheart. Dopamine was
weaned off successfully and his pressures were maintained. For
the remainder of his admission, there was no issue with
hypotension. He became hypertensive with agitation while he was
delirious immediately following extubation. His pressures were
stable and were able to tolerate adding metoprolol xl and
lisinopril.
.
Vfib arrest:
Pt had multiple runs of Vfib at both outside hospital and here,
s/p CPR, defibrillation and pressor support in the cath lab. He
was given antiarrhythmic medications including initiation of
amiodarone drip in cath lab. He was monitored on telemetry. He
was started on cooling per Arctic Sun protocol s/p arrest for
neuroprotection. He did not have any further ventricular
arrhythmias while in house.
.
Respiratory Failure:
Patient was intubated on transfer from OSH. Likely hypoxemic
resp failure given FiO2 100% and low O2 saturation; [**2-13**] volume
overload after STEMI and vfib arrest. Pt diuresed significantly
after 100mg IV lasix in cath lab. After several days when
hemodynamic stability was achieved, he was started on a
furosemide drip which improved his oxygenation on the
ventilator. He was also found to have an acinetobacter
pneumonia with thick sputum and intermittent mucus plugging.
Initial attempts at extubation were unsuccessful in the setting
of extreme agitation when sedation wore off; patient could not
tolerate spontaneous breathing trials either due to anxiety. A
trial of precedex was not effective in sedating patient. On
[**9-17**], he was extubated successfully after weaned off propofol.
He was quickly transitioned from shovel mask to nasal cannula
and then to room air. He maintened good oxygenation and did not
need any additional supplemental oxygenation while in house.
.
Altered Mental Status: He was delirious after extubation with
significant agitation and dillusions. He was actively
hallucinating about various things over the course the week
after extubation. He was never violent. He was cognizent of
his family. He was given Zyprexa for acute agitation and
psychiatry was consulted along with behavioral neurology. He
was placed on standing Zyprexa QHS with extra prn doses made
available for acute agitation. After approximately 5 days of
agitation, he cleared. He was oriented to person, place, date,
and to situation. He had good insight into his condition and
why he was in the hospital. He also had insight into the fact
that he was not mentally at baseline yet. The Zyprexa was
discontinued once the delirium and agitation resolved. On
discharge he was mentally appropriate.
.
s/p fall:
Likely [**2-13**] EtOH intake and cardiogenic shock in setting of
concurrent MI. Head CT could not be done initially because
patient was unstable but eventually showed no acute bleed; it
did show an "ill-defined hypodensity in the left
parieto-occipital region at the border zone of the left MCA and
PCA suggestive of subacute to chronic infarct," unchanged from
previous MRI from [**2176**] that wife had brought in from an outside
hospital.
.
R Thumb fracture:
Likely incurred after fall (pt with facial and chest
lacerations). Appears displaced. Ortho was consulted on day of
admission and his thumb was reduced with good result on f/u
post-reduction films. Thumb was placed in a splint for three
weeks, and was recommended followup with orthopedics in 2
months. However once the patient was awake, his thumb
dislocation is a chronic problem that happens relatively
frequently.
.
Seizure Disorder:
Per wife, patient has temporal lobe epilepsy. He was continued
on home levetiracetam 500mg [**Hospital1 **].
.
GERD:
Pt uses PPI at home, but started on plavix therapy in setting of
recent MI.
Started on famotidine IV renally dosed
.
Patient was seen by physical therapy and was discharged to a
rehabilitation facility specializing in neurologic
rehabilitation.
.
He was full code for this admission.
Medications on Admission:
Duloxetine 60mg cap [**Hospital1 **]
levetiracetam 500mg [**Hospital1 **]
HCTZ 25mg daily
Metop succinate 50mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day with aspirin for at least one month, do
not stop taking unless Dr. [**Last Name (STitle) 171**] says it is OK.
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for Fever.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day): to rash on right lower back.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day): give with meals.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: goal INR 2.0-3.0.
16. Outpatient Lab Work
please check INR on Thursday [**9-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Myocardial infarction
Ventricular fibrillation
Right thumb dislocation
Acitinobacter Pneumonia
Acute Systolic Dysfunction, EF now 40%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you had a heart attack
and suffered a serious heart arrhthmia called ventricular
fibrillation. You required CPR and defibrillation to restart
your heart. You were transferred from an outside hospital to
[**Hospital1 18**] for management of your condition. You were taken to
cardiac catheterization and were resuscitated multiple times for
the arrhythmia involving medications, CPR, and defibrillation.
You were placed on an external pumping device to keep your blood
circulating while your heart was initially very weak called a
TandemHeart. Given the severity of your heart attack you were
also placed in a hypothermic state to protect your brain and
heart in the acute state of your illness. You developed a
pneumonia while on the mechanical ventilator which was treated
with antibiotics. You were also found to be somewhat delirious
for several days, but improved greatly with time.
.
The following changes were made to your medications:
- Start aspirin and Plavix to prevent the stent in your heart
from clotting off. It is very important that you take this every
day for at least one month and possibly longer. Do not stop
taking unless Dr. [**Last Name (STitle) 171**] tells you to.
- Decrease the Toprol to 25 mg daily
- Start Atorvastatin to prevent blockages in your coronary
arteries
- Start Lisinopril to lower your blood pressure and help your
heart recover from the heart attack.
- Stop taking HCTZ
- Start taking Thiamine and Folic acid to correct nutritional
deficiencies
- Start senna to prevent constipation
- Start Tylenol for any fevers or pain
- Start Calcium with meals as your Calcium level has been low
- Start Amiodarone to prevent the atrial fibrillation from
returning.
- Start Clotrimazole cream to treat the rash on your back
- Start Warfarin to prevent blood clots from your atrial
fibrillation
.
Weight yourself every day and call Dr. [**Last Name (STitle) 18542**] if your weight
increases more than 3 pounds in 1 day or 6 pounds in 3 days.
Followup Instructions:
Please be sure to keep your followup appointments.
.
Gastorenterology:
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 74235**] MD
Address: [**Location (un) **] [**Apartment Address(1) 8537**]
[**Location (un) **] [**Numeric Identifier 74236**]
Phone: [**Telephone/Fax (1) 74237**]
Specialty: GE - Gastroenterology
Date/time: Wed [**10-3**] at 2:30pm.
Fax: [**Telephone/Fax (1) 74238**]
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2181-10-24**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD and [**First Name4 (NamePattern1) 751**] [**Last Name (NamePattern1) 16157**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Neurology:
[**Last Name (LF) **], [**Name6 (MD) **] P, MD
Department:Neurology
Division:Behavioral Neurology Unit
Operating Unit:[**Hospital1 18**]
Office Phone:([**Telephone/Fax (1) 1703**]
Office Fax:([**Telephone/Fax (1) 9382**]
Patient Location:[**Hospital Ward Name 860**] 253
Date/Time: Thursday [**11-8**] at 2:00pm.
.
Electrophysiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone: [**Telephone/Fax (1) 62**]
Date/Time: [**11-30**] at 1:20pm
Completed by:[**2181-9-26**]
ICD9 Codes: 4275, 4271, 2762, 4280, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4616
} | Medical Text: Admission Date: [**2189-8-30**] Discharge Date: [**2189-8-31**]
Date of Birth: [**2124-6-10**] Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Post fossa hemorrhages
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65M who was in his usual state of health until lunch time today
when complained of a sudden onset of headache. Patient then went
and took some ASA and showered. He then began vomiting. Wife
noted him to be diaphoretic and he complained of dizziness. His
wife then helped him down to the ground where he became
unresponsive but continued moaning. EMS was called. On their
arrival patient did complain of difficulty breathing and feeling
that his tongue was swollen and that he may be having a allergic
reaction to tomatoes. He was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
where
they noted respiratory distress and intubated him. Intubation
was
difficult and the patient per report aspirated on his vomit. A
Head CT at the OSH showed bilateral posterior fossa hemorrhages,
per ER report his neuro exam was poor and he was transferred to
[**Hospital1 18**] for further evaluation/intervention.
On arrival to [**Hospital1 18**], patient is intubated and on no sedatives or
paralytics. A repeat head CT was performed which showed
bilateral
large posterior fossa hemorrhages L>R with some intraventricular
extension.
Past Medical History:
HTN
Kidney stones
Social History:
Married; has one daughter and two sons. Retired federal
government employee since age 55, has been consulting for budget
analysis for the last ten years. Occasional cigar smoker.
Occasional ETOH socially. Wife reports he is quite active and
currently doing alot of physical work on a home.
Family History:
Father and grandfather deceased from MI. No stroke or aneurysm
history in family that wife is aware of.
Physical Exam:
On admission:
Gen: Intubated; no sedatives or paralytics; unrestrained
HEENT: normocephalic, pupils 4mm and fixed.
Extrem: Warm and well-perfused.
Neuro:
No eye opening. Pupils are 4mm and nonreactive/fixed. No
corneals
bilaterally. Weak cough reflex. No movement to BUE with noxious
stim; BLE withdraw to noxious stim.
Expired
Pertinent Results:
Head CT [**2189-8-30**] from OSH:
Large bilateral posterior fossa hemorrhage L>R. No
intraventricular extension; no hydrocephalus.
CTA Head at [**Hospital1 18**] [**2189-8-30**]:
Large bilateral posterior fossa hemorrhage L>R, appears stable
from last CT. New intraventricular extension with new dilation
of
ventricles. Early L>R tonsillar herniation is now present. CTA
shows a possible L sided AVM underlying hemorrhage.
Brief Hospital Course:
65M transferred to [**Hospital1 18**] for bilateral posterior fossa
hemorrhages. Patient was transferred intubated. On examination,
neuro exam was poor with fixed bilateral pupils, no corneals
bil, no BUE movement, and withdraws BLE to noxious. Repeat
imaging showed the hemorrhage to be stable but there was new
intraventricular extension and early tonsillar herniation noted.
He received Mannitol 100 gm IV x1 in the ER. He was admitted to
the Neuro ICU under Dr [**Last Name (STitle) **].
Given patient's poor exam and imaging, we discussed prognosis
and surgical options with the wife and son. We offered surgical
decompression and resection of AVM but advised given the
severity of the hemorrhage and the extent of the bleed we did
not feel there would be any meaningful recovery. After a long
discussion with the family, it was decided to not undergo
surgery. Patient will be admitted and kept comfortable until
remaining family arrives.
He was made DNR while awaiting further family to arrive. On the
afternoon of [**8-31**] his family fully arrived and decided to make
him CMO. He passed away soon after being made CMO with family at
his bedside.
Medications on Admission:
Lisinopril 20 mg PO daily
HCTZ 25 mg PO daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Bilateral posterior fossa hemorrhages
Intraventricular hemorrhage
Cerebral edema/compression
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
N/A
Completed by:[**2189-8-31**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4617
} | Medical Text: Admission Date: [**2127-3-7**] Discharge Date: [**2127-3-14**]
Date of Birth: [**2064-4-1**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Shortness of breath, Left leg swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
62yo woman with history of hypertension presented to [**Hospital 191**] clinic
on day of admission with multiple complaints including chest
pain radiating to her left shoulder, shortness of breath on
exertion, cough, and worsening LLE swelling and pain x 2 days.
On initial exam, her vitals were stable: T 97.7, BP 126/84, P65,
RR10 98%RA. Her exam was notable for LLE swelling and warmth.
She was sent to the ED for further evaluation. In the ED, her
evaluation was notable for the following: clear chest film; CTA
demonstrating bilateral PE's; LLE LENI with extensive DVT in
left common femoral, superficial femoral, and popliteal veins,
also extending into greater saphenous; also found to have acute
coagulopathy, anemia, and thrombocytopenia.
She was also found to have BRBPR. GI was consulted, and
recommended to perform bowel prep in anticipation of colonoscopy
in AM. Surgery was consulted as well, and agreed with plan for
anticoagulation for PE's and further investigation for GI
bleeding by GI.
.
On interview on the floor she is alert, oriented, very pleasant,
and in no distress. She confirms that over the past several days
she has had exertional dyspnea, chest pain (described as dull
pressure, [**5-29**], mid-sternal with radiation to bilateral
shoulders, not clearly pleuritic) and worsening LLE swelling and
pain. She also reports several recent bouts of upper respiratory
symptoms after exposure to her grandson who is an infant in
daycare (reportedly had RSV bronchiolitis recently). Otherwise,
she denies any fever, chills, n/v, lymphadenopathy, night
sweats, unintentional weight loss, abdominal pain/increased
girth, or pruritus. She does report one episode of BRBPR on day
prior to admission after having bowel movement. ROS otherwise
negative. She also reports a worsening dry cough since she has
been in the hospital. She did not have a flu shot. She does not
report any long plane/car trips, no prolonged bed-rest. She
notes that the swelling in her L leg has improved since being in
the hospital.
Past Medical History:
Hypertension
Osteopenia
h/o pneumonia
liver hemangioma
psoriasis
rosacea
Diverticulosis
Social History:
Lives in [**Location 2624**], MA and summers on [**Location (un) 945**]. Married, two adult
children. Retired. No etoh/drugs/tobacco. Very active involved
in re-modelling her house. Babysits her grandson once per week.
Prior to onset of multiple viral illnesses last fall she did the
treadmill for 25 mins at speed 3.3 3-4 times per week.
Family History:
Father and mother with heart disease. Father had a triple A.
HTN. No blood clots. Father nieces with stomach cancer. Aunt
with lung cancer but was a smoker.
Physical Exam:
99.6, 92, 124/61, 18, 99% 2L nc
.
gen a/o, no distress, speaking in full sentences, no accessory
resp muscle use
heent moist mm, anicteric
neck supple, from, no meningeal signs, no JVD, no
lymphadenopathy
cv rrr, no m/r/g
resp CTA with decreased breath sounds in bilateral bases L>R
abd obese, soft, nabs, nt, no hepatosplenomegaly
extr asymmetric 2+ edema and erythema in LLE
neuro grossly non-focal
Pertinent Results:
[**2127-3-6**] 06:50PM WBC-11.7*# RBC-3.75* HGB-11.4* HCT-31.8*
MCV-85 MCH-30.2 MCHC-35.7* RDW-13.7
[**2127-3-6**] 06:50PM NEUTS-81.0* LYMPHS-13.3* MONOS-3.7 EOS-1.6
BASOS-0.3
[**2127-3-6**] 06:50PM PLT SMR-VERY LOW PLT COUNT-61*# LPLT-2+
[**2127-3-6**] 06:50PM PT-15.9* PTT-44.8* INR(PT)-1.4*
[**2127-3-6**] 06:50PM FIBRINOGE-65*
[**2127-3-6**] 06:50PM calTIBC-281 HAPTOGLOB-248* FERRITIN-192*
TRF-216
[**2127-3-6**] 06:50PM HOMOCYSTN-12.4
[**2127-3-6**] 06:50PM GLUCOSE-119* UREA N-27* CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2127-3-6**] 06:50PM ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-333*
CK(CPK)-276* ALK PHOS-82 AMYLASE-38 TOT BILI-0.5
[**2127-3-6**] 06:50PM CK-MB-3
[**2127-3-6**] 06:50PM cTropnT-<0.01
[**2127-3-7**] 05:30AM D-DIMER-8945*
CTA CHEST:
1. Extensive bilateral pulmonary emboli, with probable
developing infarction in the left lingula.
2. Left pelvic vein clot from imaged portion of common femoral
to the confluence of the common iliac veins, likely the source
of pulmonary emboli. No definite extension to the right common
iliac vein or IVC.
3. Large hemangioma in liver.
4. Colonic diverticulosis without diverticulitis.
5. Left adnexal cyst, unusual in a postmenopausal patient. This
should be further evaluated with pelvic ultrasound on a
nonemergent basis.
LENI: Extensive acute DVT within the entire left lower
extremity deep venous systems. No right DVT.
ECG: Sinus rhythm. Non-specific junctional ST segment
depressions. Compared to the previous tracing this finding is
new.
TTE:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The left
ventricular inflow pattern suggests impaired relaxation. There
is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic
pericardial effusion.
PELVIC US: Fibroids, follicular activity left ovary, right ovary
not seen, thrombus in the left iliac vein
Brief Hospital Course:
1) DVT/PE:
Patient was started on anticoagulation with heparin for
extensive PE/DVT (LLE). This was continued despite bleeding.
Once the bleeding has stabilized, she was started on coumadin.
She was discharged on a lovenox bridge to coumadin.
In terms of workup for cause of this thrombosis, pt had a pelvic
US to further evaluate mass since on CT as potential malignancy.
But there was no evidence of ovarian malignancy. She was up to
date on other cancer screening. Factor V leiden and prothrombin
gene mutation were pending at time of discharge. The rest of
the hypercoagulable workup will have to be done once acute
thrombosis resolves.
The left leg swelling improved throughout the admission. Pt was
instructed to keep the leg wrapped most of the day. And to keep
it elevated when lying in bed or sitting.
..
2) GI BLEED: Flex sig showed diverticulosis so this bleeding
was secondary to that. Pt did have blood loss anemia requiring
transfusions. During the last 5days of the admission, there was
no clinical bleeding and her Hct was stable to slightly
improving. Aspirin was held. Verapamil was also held and not
restarted as pt's BP was well controlled in house.
..
3) HTN: As above, verapamil was held.
..
4) COAGULOPATHY: On admission, pt had thromboctyopenia, low
fibrinogen. This was felt to be due to consumption and factors
improved once anticoagulation was started. There was no
evidence of frank DIC.
..
5) PNEUMONIA: Several days into the admission, pt developed a
low grade temperature and cough. Though this was most likely
due to pulmonary infarction, levaquin was started for pneumonia.
Pt's cough improved with this and she completed a 5d course of
levaquin before discharge.
Medications on Admission:
ASPIRIN 81 mg
BETAMETHASONE VALERATE 0.1 % to skin
METROGEL 1 % to skin
MULTIVITAMIN qD
VERAPAMIL HCL CR 240 MG qD
VIACTIV 500-100-40 mg-unit-mcg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 1 weeks.
Disp:*14 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Deep Venous Thrombosis
Pulmonary embolism
Diverticular hemorrhage
Pneumonia
Discharge Condition:
Good.
Discharge Instructions:
Take medications as prescribed. You should not take aspirin or
verapamil until you are reassessed by Dr. [**First Name (STitle) 216**]. Do not take a
multivitamin or anything else with vitamin k as that will
counteract the coumadin.
For the next week, you can do basic daily activities but avoid
anything that requires prolonged standing, sitting (with legs
not elevated) ie driving, or walking. You can continue to use
the leg wrap during the night and part of the day. As your
swelling improves, you should not continue to need that.
Followup Instructions:
You will have your INR checked on monday with results sent to
Dr. [**First Name (STitle) 216**]. He will instruct you on whether you need to
continue lovenox and how to adjust your coumadin dose. Please
ask the VNA which lab the blood will be sent to.
Please follow up with Dr. [**First Name (STitle) 216**] late next week or early the
following week.
ICD9 Codes: 2851, 2875, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4618
} | Medical Text: Admission Date: [**2189-2-9**] Discharge Date: [**2189-2-25**]
Date of Birth: [**2110-12-14**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
monitoring s/p mechanical thrombectomy and extensive venous
angioplasty LE DVTs by IR [**2189-2-9**].
Major Surgical or Invasive Procedure:
Mechanical thrombolysis/angioplasty of DVT w/ repositioning of
IVC filter ([**2-7**], [**2-10**])
Transfusion of 2U FFPs and 2U PRBCs
XRT
History of Present Illness:
78 y.o male h.o intradural extramedullary mass (adenocarcinoma)
(originally presented as sudden back pain, progressively
worsening ascending paralysis) s/p thoracic laminectomy T4-7 and
mass resection [**2189-1-8**], surgery complicated by hemorrhage
resulting in paraplegia, s/p IVC filter for PE ppx. Pt underwent
attempted retrieval of IVC filter [**2189-2-6**], however femoral and
common iliac veins were seen to be thrombosed and procedure was
aborted. Pt went to rad onc today (brain/spine radiation) at
whic time he was noted to have worsening scrotal and LE edema
and decision was made to have pt come in for thrombolysis to
recannulize the femoral/iliac vessels with potential IVC filter
retrieval/replacement. Pt transferred to medicine for monitoring
of hematuria, HCT, monitor for PE.
.
Of note, he has been on coumadin 4mg and Dalteparin [**Hospital1 **] and INR
was noted to be 3.5 preprocedure.
.
In IR pt had extensive thrombectomy with recanalization of
thrombosis in popliteal, femoral, iliac, and IVC with mechanical
device using AngioJet and balloon angioplasty. There was good
angiographic result with some residual thrombosis. No
thrombolytics were used. His IVC filter was left in place.
During the procedure, his SBPs ranged from 120s-140s and HR in
the 80s-90s.
.
Initially, upon admission to the medicine service, SBP was
112/64. However, soon after being admitted to the medicine
service he triggered for hypotension with blood pressure as low
as 80/P. On the floor, he was also noted to be persistently
tachycardic 104-108. A stat hct was sent and revealed a drop
from 29.5 immediately post procedure to 23.6. He received 1L
Normal saline bolus with transient increase in sbps to 90s, then
returning to high 80s. Although b/l lower extremities were
swollen, there was no clear e/o hematoma in popliteal regions
nor in groin. T+S was sent and he was ordered for FFP and prbcs
and transferred to the ICU for further monitoring and care.
.
Upon arrival to the MICU a portable u/s showed no trauma to the
popliteal veins in the popliteal fossa.
.
Initally on the floor, the patient reported nausea which has
since resolved, band-like numbness across abdomen (unchanged)
and paresthesias of b/l LE (unchanged.) He denied abdominal pain
and leg pain, although sensation limited as above. Otherwise, no
fevers, chills, SOB, CP, palpitations, abdominal pain,
V/D/dysuria, +notable hematuria, -joint pains, -headache, -new
paresthesias.
Past Medical History:
- Recently diagnosed with Adenocarcinoma
(intradural/extramedullary). Mets to brain (mult cystic
enhancing lesions seeon on MRI.) CT torso showing mult densities
in the lungs, diffuse metastatic bony disease. Thought to be
from lung primary vs.prostate.
- Paraplegia (from hemorrhagic complication of thoracic
laminectomy)
- s/p IVC filter placement
- Prostate Ca s/p XRT, horomonal therapy (approximately
[**2180**]-[**2181**])
Social History:
The patient was last at a rehab facility. Formerly lived at
home with his wife. Family very involved in his care. Oldest
son, [**Name (NI) **] ([**Telephone/Fax (1) 75974**]) is his health care proxy. [**Name (NI) **] is a
retired fisherman. No tobacco use. No ethanol use.
Family History:
His mother died of blood dyscrasias, while his
father died of an unspecified cancer. He has 6 brothers and 3
sisters and they are healthy. His 6 sons are healthy.
Physical Exam:
gen-lying in bed, NAD, cooperative
vitals-T 100.3, BP 112/64 HR 110, RR 18, Sat 97% on 2L
HEENT-NC/AT, L.eye appears larger than R. PERRLA, EOMI,
anicteric, MMM.
neck: No JVD, no LAD
chest-b/l AE no W/C/R
heart-S1S2 RRR no m/r/g
abd-+bs, +multiple ecchymotic areas ([**3-14**] fragmin?), soft, NT,
ND, -guarding/rebound.
groin-R.groin-no masses, no bruits, bandage C/D/I
ext-no C/C [**3-15**]+edema up to pelvis. +b/l ankle boots in place.
0/5 motor strenght, but sensation intact to touch. 1+palpable DP
pulses, warm extremities. +compression stockings over popliteal
area.
neuro-AAOx3, CN 2-12 intact, motor [**6-15**] B/L UE.
Pertinent Results:
Admit Labs:
------------
[**2189-2-9**] 06:00PM WBC-6.0 RBC-3.22* HGB-10.0* HCT-29.5* MCV-92
MCH-31.1 MCHC-34.0 RDW-12.7
[**2189-2-9**] 06:00PM PLT COUNT-277
[**2189-2-9**] 12:26PM PT-33.6* INR(PT)-3.5*
[**2189-2-10**] 01:48AM BLOOD Glucose-136* UreaN-18 Creat-0.6 Na-136
K-6.0* Cl-103 HCO3-28 AnGap-11
[**2189-2-10**] 01:48AM BLOOD ALT-29 AST-84* LD(LDH)-1258* AlkPhos-100
TotBili-2.2*
[**2189-2-10**] 01:48AM BLOOD Calcium-7.9* Phos-4.8* Mg-2.1
[**2189-2-10**] 03:21AM BLOOD Hapto-40
[**2189-2-10**] 01:09AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.024
[**2189-2-10**] 01:09AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-MOD
[**2189-2-10**] 01:09AM URINE RBC-[**12-31**]* WBC->50 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2189-2-10**] 01:09AM URINE CastGr-0-2 CastHy-0-2
[**2189-2-10**] 1:09 am URINE Source: Catheter.
**FINAL REPORT [**2189-2-13**]**
URINE CULTURE (Final [**2189-2-13**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- <=0.25 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Other Labs:
------------
[**2189-2-11**] 11:22AM BLOOD Cortsol-5.2
[**2189-2-11**] 01:24PM BLOOD Cortsol-25.4*
[**2189-2-11**] 04:37AM BLOOD PSA-5.7*
[**2189-2-20**] 04:20PM
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT)
Fibrinogen, Functional 516* mg/dL 150 - 400
D-Dimer 1699* ng/mL 0 - 500
[**2189-2-20**] 04:20PM
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT)
Fibrin Degradation Products 0-10 ug/mL 0 - 10
HEPARIN DEPENDENT ANTIBODIES POSITIVE
COMMENT: Positive for Heparin PF4 Antibody by [**Doctor First Name 1059**].
(optical density 2.3)
.
[**Numeric Identifier 75975**] PTA VENOUS [**2189-2-9**] 1:48 PM
PROCEDURE AND FINDINGS: After explaining the risks and benefits
of the procedure, informed consent was obtained from the patient
(after translation) and from his healthcare proxy (son). The
patient was placed prone on the angiographic and both popliteal
areas were prepped and draped in standard sterile fashion. A
preprocedure timeout was performed.
After injection of 1% lidocaine and using ultrasound guidance,
access was gained into the right popliteal vein with a
micropuncture needle. A 0.018 guidewire was advanced through the
micropuncture needle into the distal superficial femoral vein
under fluoroscopic guidance. A micropuncture needle was
exchanged for a 4.5 French micropuncture sheath. Venogram was
obtained with injection of contrast through the micropuncture
sheath, which demonstrated thrombosis extending from the
popliteal vein to the femoral vein. A 0.035 Bentson guidewire
was advanced through the micropuncture sheath into the high IVC
under fluoroscopic guidance. A micropuncture sheath was
exchanged for a 6 French vascular sheath. A 5 French Kumpe
catheter was advanced into the iliac vein and SVC and a venogram
was obtained, which demonstrated thrombosis in the right iliac
vein and IVC, below the IVC filter.
After injection of 1% lidocaine and using ultrasound guidance,
access was gained into the left popliteal vein with a
micropuncture needle. A 0.018 guidewire was advanced through the
micropuncture needle into the femoral vein. A micropuncture
needle was exchanged for a 4.5 micropuncture sheath. A venogram
was obtained with injection of contrast through the
micropuncture sheath, which demonstrated thrombosis extending
from the popliteal to femoral vein. A 0.035 [**Last Name (un) 7648**] wire was
advanced through the micropuncture sheath into the high IVC
under fluoroscopic guidance. A micropuncture sheath was
exchanged for a 6 French vascular sheath.
Mechanical thrombectomy was performed from the IVC to both
popliteal veins with the AngioJet thrombectomy device. Venogram
after mechanical thrombectomy was obtained with injection of
contrast through right vascular sheath, which demonstrated
multiple stenoses/residual mural thrombosis of the left
popliteal and left femoral vein. It was decided to do balloon
dilatation from IVC to both popliteal veins. Balloon dilatation
was performed from both iliac veins to both popliteal veins with
6 mm x 4 cm balloons. After then, balloon dilatation was again
performed from the IVC to both femoral veins with 8 mm x 4 cm
balloons.
Venograms after balloon dilatation was obtained with injection
of both popliteal veins sheaths, which demonstrated marked
interval improvement of venous flow with small residual mural
thrombosis. Iliac venogram was then obtained through a 5 French
Omniflush catheter which was placed in the left common iliac
vein, which demonstrated marked improvement in the thrombosis
and venous flow from the iliac vein into the IVC.
Popliteal vein sheaths were removed and manual compression was
held for 10 minutes until hemostasis was achieved. A compression
dressing was applied at both popliteal vein puncture sites.
Moderate sedation was provided by administering divided doses of
25 mcg of fentanyl and 0.5 mg of Versed throughout the total
intraservice time of 55 minutes during which the patient's
hemodynamic parameters were continuously monitored.
COMPLICATION: Hematuria developed right after the procedure and
is likely due to hemolysis from the Angiojet thrombectomy. Good
hydration should be mantained and creatinine checked.
IMPRESSION: Thrombosis involving the bilateral popliteal,
femoral and iliac veins and IVC, below the IVC filter.
Successful recanalization of thrombosis in popliteal, femoral,
iliac, and IVC with mechanical thrombectomy using AngioJet and
balloon angioplasty, with good angiographic result and some
residual mural thrombosis.
.
CT LOW EXT W/O C BILAT [**2189-2-10**] 12:02 AM
CT OF THE ABDOMEN WITH NO IV CONTRAST ADMINISTRATION: The
visualized portion of the lung bases demonstrate dependent
atelectatic changes and a small bilateral pleural effusion.
Small axial hiatal hernia is also visualized. The visualized
portion of the heart and great vessels appear normal.
The liver, spleen, left adrenal gland, gallbladder, pancreas,
common bile duct, stomach, and loops of small bowel and large
bowel appear normal. The right adrenal gland contains an adenoma
measuring 18 x 17 mm. Both kidneys contain multiple hypodense
lesions which most likely represents cysts. The aorta has normal
appearance. The IVC stent is noted in the infrarenal region.
Contrast is still noted in IVC suggesting residual clot. Both
kidneys are excreting the contrast material. The patient
demonstrates signs of fluid overload.
CT OF PELVIS WITH NO IV CONTRAST ADMINISTRATION: The bladder has
thickened wall and contains a Foley catheter. The prostate is
normal in appearance. The rectum and sigmoid colon contain oral
contrast. Small amount of free fluid is noted within the pelvis.
No evidence of retroperitoneal bleeding is visualized.
CT OF THE Lower extemity: There is significant amount of fluid
accumulation within the scrotum and penis related to venous
obstruction.
Diffuse fluid accumulation in soft tissues are noted.
BONE WINDOWS: No concerning lytic or sclerotic lesions are seen.
IMPRESSION:
1. No retroperitoneal bleeding is noted.
2. There is copious fluid accumulation in the soft tissues and
most prominantly in the scrotum. This is most likely related to
venous occlusion.
Persistent contrast in the venous system is most likely related
to the residual clot.
3. Right adrenal adenoma as described.
4 . Axial Hiatal hernia..
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2189-2-19**] 3:27 PM
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture with no focal lesions. There is no intra- or
extra-hepatic biliary dilation. The portal vein is patent with
anterograde flow. The common duct measures 4 mm. There is no
ascites. Sludge layers within the gallbladder, with no echogenic
gallstones identified. The gallbladder wall is not thickened,
and the gallbladder is only mildly distended. There is no
pericholecystic fluid.
IMPRESSION:
1. Gallbladder sludge without evidence of acute cholecystitis.
2. Normal hepatic echotexture. No evidence of biliary
dilatation.
.
Discharge Labs:
---------------
[**2189-2-25**] 07:20AM
COMPLETE BLOOD COUNT
White Blood Cells 9.4 K/uL 4.0 - 11.0
Red Blood Cells 3.85* m/uL 4.6 - 6.2
Hemoglobin 11.8* g/dL 14.0 - 18.0
Hematocrit 34.7* % 40 - 52
MCV 90 fL 82 - 98
MCH 30.7 pg 27 - 32
MCHC 34.1 % 31 - 35
RDW 13.9 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 292 K/uL 150 - 440
[**2189-2-25**] 07:20AM
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 12.9 sec 10.4 - 13.4
NOTE NEW REFERENCE RANGE AS OF [**2188-12-24**] 12:00A
PTT 30.3 sec 22.0 - 35.0
INR(PT) 1.1 0.9 - 1.1
[**2189-2-25**] 07:20AM
RENAL & GLUCOSE
Glucose 102 mg/dL 70 - 105
Urea Nitrogen 16 mg/dL 6 - 20
Creatinine 0.4* mg/dL 0.5 - 1.2
Sodium 136 mEq/L 133 - 145
Potassium 4.2 mEq/L 3.3 - 5.1
Chloride 100 mEq/L 96 - 108
Bicarbonate 29 mEq/L 22 - 32
Anion Gap 11 mEq/L 8 - 20
CHEMISTRY
Albumin 2.8* g/dL 3.4 - 4.8
Calcium, Total 8.0* mg/dL 8.4 - 10.2
Phosphate 3.9 mg/dL 2.7 - 4.5
Magnesium 2.0 mg/dL 1.6 - 2.6
Alanine Aminotransferase (ALT) 33 IU/L 0 - 40
Asparate Aminotransferase (AST) 18 IU/L 0 - 40
Stool C. Diff ([**2-14**]) - positive
Blood Cx ([**2-18**]) - negative x 2 sets
Brief Hospital Course:
78 y.o man with recently diagnosed adenocarcinoma (unclear
primary, lung vs. prostate likely) s/p T4-7 laminectomy c/b
hemorrhage, resulting in paraplegia, s/p IVF filter, with
increased LE/scrotal edema today now s/p mechanical
thrombolysis/angioplasty of DVT and repositioning of IVC filter.
.
1) Hypotension
Patient had decreased bp after procedure, necessitating ICU
transfer. Likely related to peri-procedural complication given
time course and acute blood loss. No clear source of aneurysm or
hematoma b/l popliteal and right groin on bedside U/S performed
by IR. CT scan done and did not show RP bleed. BP improved
after fluid and blood transfusion (got 2U PRBCs and 2U FFP).
Had cosyntropin stim test which did not show any evidence of
adrenal insufficiency. BP fluctuated intermittently during
course of hospitalization. He did receive intermittent doses of
lasix (IV and PO) which also affected blood pressure. On
discharge, SBP was in mid-90s to low-100s. Patient did not have
symptoms of lightheadedness of dizziness.
.
2) Hematuria
Had hematuria post-procedure which is common occurrence due to
jets in thrombectomy which can cause hemolysis. This
subsequently resolved. Hematuria later recurred after he
received Lepirudin (see below). He was seen by the urology
service who recommended intermittent flushes or CBI (250-500cc
up to twice a day as needed). Upon discontinuation of
Lepirudin, hematuria resolved and further flushes were not
needed. He will need follow up with urology after discharge.
.
3) Extensive Lower extremity DVTs/Heparin-induced
thrombocytopenia
Although IVC filter had been replaced and mechanical
thrombectomy achieved some level of success, the patient had
extensive residual clot burden from IVC filter to the popliteal
veins. Further interventions were discussed with interventional
radiology. They felt that repeat mechanical thrombectomy would
not be beneficial. Only definitive treatment would be
thrombolytics, however these would be contraindicated given
brain mets. Case also discussed with vascular surgery who did
not feel there would be a surgical option. Given the likely
failure of coumadin (INR was therapeutic when clot developed),
coumadin was stopped and the patient was placed on Lovenox at
the recommendation of the heme-onc service. A Factor Xa level
was checked and was therapeutic. However, over the course of
his Lovenox therapy, the patient's platelet count decreased from
264 to 125 over the course of 8 days. Lovenox was stopped and
the patient was started on Lepirudin and Heparin Dependent
Antibodies were sent off. The patient developed the hematuria
(as above) on Lepirudin, however his Hct was stable. Heparin
antibody subsequently came back positive (optical density of 2.3
which is grossly positive). Given these findings, the patient
should never be given heparin products. He was switched over to
Fondaparinux, which he tolerated well (no evidence of a decrease
in blood clots).
.
4) Lower Extremity and Scrotal Edema
This is secondary to extensive clot burden. Legs and scrotum
were elevated and TEDS were used. Lasix was started to try to
mobilize some fluid. Although patient had good urine output
with Lasix, edema was essentially unchanged. Lasix had to be
intermittently stopped due to low blood pressures. He should
continue with compression stockings and Lasix as tolerated to
help with the edema.
.
5) Metastatic adenocarcinoma - unclear primary (lung vs.
prostate) w/ paraplegia
Mets involving brain, spine, bone. He completed his radiation
therapy of the brain and spine and completed the . He was also
continued on dexamethasone. A PSA was checked and was 5.7. Per
report, it was <1 sometime last year. This was discussed with
oncology, who did not necessarily feel this indicated recurrence
of the prostate ca. The patient will need to follow up in
thoracic oncology, the Brain Tumor Center, and Urology (either
his primary urologist, Dr. [**Last Name (STitle) 11789**] or Urology at [**Hospital1 18**]).
Prior to discharge, he was seen by his neuro-oncologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] who will also follow up with him as an outpatient. In
discussing the case with Dr. [**First Name (STitle) 13014**] of Radiation oncology, the
plan will be to do a slow taper of the patient's dexamethasone
over the next few weeks. He is currently on 1mg [**Hospital1 **], and will
be decreased by 0.5mg per week unless directed otherwise by the
doctors in the [**Name5 (PTitle) **] Tumor Center.
.
6) Sacral Decub/Scrotal skin breakdown
The patient had a stage II sacral decubitus ulcer as well as
some scrotal skin breakdown. He was seen by the wound care
nurse who made recommendations on wound care which were
implemented.
.
7) Urinary Tract Infection - MSSA/Pseudomonas
He was diagnosed with a urinary tract infection and treated with
a 2-week course of Ciprofloxacin (last dose on [**2-24**]).
.
8) Anemia
After his transfusion, the patient's Hct remained stable between
34-36.
.
9) C. diff Colitis
The patient developed diarrhea while on antibiotics. Stool for
C. Diff was positive. The patient was started on Flagyl 500mg
tid for C. Diff. He should remain on this until [**3-9**] (2 weeks
after last dose of Cipro was given). The patient had
intermittent passage of jelly-like stool, thought to be
secondary to the infection.
.
10) Goals of care
Discussions held with multiple members of the family, including
son [**Name (NI) **], who is the health care proxy, regarding overall
goals of care. The palliative care team was also involved.
Overall disease process/prognosis was also discussed with
patient via the hospital interpreter. The patient will be
discharged [**Hospital 6595**] Rehabilitation Nursing Center in
[**Hospital1 **]. During the course of this rehabilitation and through
further discussions with the patient's team of doctors [**First Name (Titles) **] [**Name5 (PTitle) 75976**], the family will decide about home hospice. This will
be facilitated through the palliative care service here.
Medications on Admission:
tylenol
MOM
fleet enema
dulcolax supp
celexa 10mg daily
dexamethasone 1mg [**Hospital1 **]
MVI
colace 100mg [**Hospital1 **]
fragmin [**Numeric Identifier 14900**] units SC BID
coumadin 3mg daily
percocet 5/325 1 q4hprn
protonix 40mg daily
ambien 10mg qhs
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Dexamethasone 0.5 mg Tablet Sig: as directed Tablet PO as
directed for 4 weeks: Take 1mg [**Hospital1 **] for 7 days. Then take 1mg in
the morning and 0.5mg in the evening for 7 days. Then take
0.5mg [**Hospital1 **] for 7 days. Then take 0.5mg once daily for 7 days.
Then stop medication.
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks: Last dose on [**3-9**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp<95.
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
18. Aquaphor Ointment Sig: moderate amount Topical twice a
day: dry tissue, forehead, left upper chest, b/l lower
extremities. Also to scalp as needed for discomfort. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehab
Discharge Diagnosis:
1) Lower extremity deep venous thrombosis
2) Lower extremity and scrotal edema secondary to above
3) Adenocarcinoma of unclear primary with lesions in lung,
spine, and brain
4) Urinary Tract Infection (MSSA/Pseudomonas)
5) Stage II Sacral Decubitus Ulcer w/ skin breakdown of scrotum
6) Prostate Cancer
7) Hematuria
8) C. Diff Colitis
9) Hypotension - intermittent
10) Scalp pain - likely secondary to XRT
11) Heparin-Induced Thrombocytopenia
Discharge Condition:
Afebrile, vital signs stable. Still with significant lower
extremity and scrotal edema.
Discharge Instructions:
You have an extensive blood clot going down most of the lower
half of your body. Due to this clot blocking the return of
blood flow from your legs and scrotum, you have developed
significant leg and scrotal swelling. Attempts to remove the
clot through mechanical means were only partially successful.
The definitive treatment of thrombolysis can't be done because
you have metastatic lesions in your head and would be at very
high risk for bleeding. It appears that the coumadin you were
previously taking did not work to prevent the spread of clots.
Therefore, you were switched to a diffent blood-thinning
medications, Lovenox. Unfortunately, you developed a reaction
to this medicine (decrease in your platelet counts - Heparin
Induced Thrombocytopenia), for this reason you were changed to
another medication, Fondaparinux. You will need to remain on
this medication indefinitely. You will need to watch for signs
of bleeding, such as blood in your urine or stool.
.
You were treated for a urinary tract infection with
Ciprofloxacin for 2 weeks. As a result of receiving necessary
antibiotics, you developed C. Difficile colitis (an infection in
your colon). You were started on another antibiotic for this
(Flagyl). This antibiotic will need to be continued until [**3-9**]
(2 weeks after your Cipro was stopped).
.
You completed the course of radiation therapy to the brain and
spine. You will need to follow up in the Brain tumor clinic as
well as the thoracic oncology clinic.
.
Call your doctor or return to the emergency room if you should
develop chest pain, shortness of breath, worsening headache,
blurry vision, increased weakness or numbness, or significant
bleeding.
Followup Instructions:
Thoracic [**Hospital **] Clinic: [**0-0-**]. Please call to set up a
follow-up appointment.
.
Brain Tumor/Radiation Oncology: You will be contact[**Name (NI) **] by the
Brain [**Hospital 341**] Clinic for a follow up appointment on [**3-9**].
Alternatively, if you do not hear from the clinic, you can call
[**Telephone/Fax (1) 1844**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] of
Radiation oncology and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] of Neuro-Oncology.
.
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. [**Telephone/Fax (1) 8572**]. Please call to
arrange follow up after discharge from rehab.
.
Urology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11789**]. ([**Telephone/Fax (1) 75977**]. You will need to
set up a follow up appointment with him to follow up on your
hematuria (blood in urine), management of your foley catheter,
and your elevated PSA found during this hospitalization.
Alternatively, if you would like to consolidate all of your care
at [**Hospital1 18**], you can schedule an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3748**], ([**Telephone/Fax (1) 8791**].
.
Palliative Care: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]. ([**Telephone/Fax (1) 75978**]. Can call to
further discuss options for palliative care.
ICD9 Codes: 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4619
} | Medical Text: Admission Date: [**2160-7-21**] Discharge Date: [**2160-7-25**]
Date of Birth: [**2108-7-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a right handed 52-year-
old male with past medical history significant for [**Year (4 digits) 499**]
cancer status post resection in [**2137**] presenting with
headaches and neck pain for the past 8 weeks. He states that
just after the Fourth of [**Month (only) 205**] he was at work, which was
computer repair, and he developed a headache, gradual onset,
pressure-type feeling mostly in the back of his head, not
accompanied by visual disturbance, diplopia, slurred speech,
numbness, weakness, or difficulty with word finding, or
comprehension. Tylenol and aspirin did not much help the
pain. The headache continued accompanied by neck pain. He
said about a week after the headache started he was going to
play golf, but he again had the exact same symptoms. He
called his primary care physician who told him that he may
have meningitis and that it would go away on its own. Mr.
[**Known lastname 31905**] had not had any fevers, nausea, vomiting, or
diarrhea. He says that he thought he had poison [**Female First Name (un) **] on his
hands a couple of weeks before the headaches began. However,
the headaches are not resolved.
PAST MEDICAL HISTORY: Significant for [**Female First Name (un) 499**] cancer status
post resection in [**2137**], gastroesophageal reflux disease,
hypertension.
ALLERGIES: Penicillin.
MEDICATIONS: Prilosec.
SOCIAL HISTORY: Works in computer repair. Smokes one pack
per day for 25 years; quit 5 years ago. Drinks 12 beers a
week.
FAMILY HISTORY: Father had [**Name2 (NI) 499**] cancer and died of an
myocardial infarction, mother of lung cancer. No strokes in
the family.
PHYSICAL EXAMINATION: Temperature 97.9, blood pressure
161/84, heart rate 85, respirations 12, O2 sat 98 percent.
In general, in no acute distress. HEENT: Anicteric sclerae,
no injection. Neck: Supple. Lungs: Clear. Heart:
Regular rate and rhythm. Abdomen: Soft. Extremities:
Warm. Neurologic: Is awake, alert, oriented times 3.
Cooperative with exam. His pupils are equal bilaterally.
EOMI is full. Nystagmus is positive with bilateral gaze.
Face is symmetric. Tongue deviated to the right. Upper
extremities are [**4-2**]. Reflexes are 1 plus in his upper and
lower extremities. He has [**4-2**] motor strength. His reflexes
are 2 plus throughout.
LABORATORY DATA: Sodium was 141, potassium was 3.8, 104/28,
16 for BUN, 1.0 for creatinine, 47 for hematocrit.
MRI/MRA: Cystic lesion in the left cerebellum with moderate
herniation of the cerebellar tonsil of the foramen magnum.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery service with q. 1-hour vital signs. He was
admitted to the Intensive Care Unit service. Was started on
Decadron 4 mg q. 6h. He was given gastrointestinal
prophylaxis and insulin sliding scale and he was preopped for
surgery. Neurology and Neuro-Oncology saw the patient and
recommended the patient start on Mannitol 25 mg q. 6h. He
should start on Dilantin, normal saline, no hypotonic fluids,
keep his head of bed at 45 degrees, and frequent neuro signs
as had already been done.
On [**2160-7-22**] he underwent a craniotomy for resection of
cerebellar mass which was felt to be hemangioblastoma.
Postoperatively he was awake, alert, oriented times 3, still
had nystagmus in his bilateral lateral gaze. Tongue deviated
to the right. Face was symmetric. He remained in the PACU
overnight where he remained neurologically intact on his
first postoperative day. He was transferred to the Surgical
unit where he was seen by Physical Therapy, who recommended a
home safety evaluation and to help with his balance.
On the second postoperative day he was awake, alert, oriented
times 3. His Dilantin was weaned and he was discharged to
home with the following instructions: To have his staples
removed 10 days from his surgery, to follow up in the Brain
[**Hospital 341**] Clinic, to watch for any signs and symptoms of
infection, and not to get his staples wet.
DISCHARGE DIAGNOSES:
1. Cerebellar mass status post craniotomy.
2. History of hypertension.
3. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2160-10-30**] 11:43:53
T: [**2160-10-30**] 14:54:21
Job#: [**Job Number 31906**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4620
} | Medical Text: Admission Date: [**2161-8-27**] Discharge Date: [**2161-9-4**]
Date of Birth: Sex:
Service:
DIAGNOSIS: Metastatic carcinoma and respiratory failure.
HISTORY OF PRESENT ILLNESS: The patient is a delightful 73-
year-old gentleman who was diagnosed with metastatic squamous
cell carcinoma of the lung. He underwent chemoradiotherapy
with his final doses of chemotherapy being 2 to 3 weeks prior
to admission. He subsequently developed dyspnea and was
treated with steroids. He continued to have respiratory
deterioration requiring intubation, and was transferred from
[**Hospital 1562**] Hospital in complete respiratory failure on a
mechanical ventilator. He was transferred for the purposes
of a lung biopsy to determine the etiology and define further
treatment.
HOSPITAL COURSE: The patient was taken to the operating room
and underwent an open lung biopsy. The pathology was
consistent with organizing pneumonia, acute lung injury, and
pulmonary embolisms. The patient continued to do poorly,
and he was made comfort measures. he died on [**2161-9-4**].
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern4) 54269**]
MEDQUIST36
D: [**2162-2-18**] 17:03:27
T: [**2162-2-19**] 11:10:35
Job#: [**Job Number 54435**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4621
} | Medical Text: Admission Date: [**2168-8-28**] Discharge Date: [**2168-8-31**]
Date of Birth: [**2093-9-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with chronic obstructive pulmonary disease,
interstitial lung disease (on home oxygen), end-stage renal
disease (on hemodialysis), and critical aortic stenosis who
came to the Emergency Department on [**8-28**] complaining
of increased shortness of breath for the past two weeks.
She was recently admitted to [**Hospital1 188**] and discharged home on [**8-14**] with similar
complaints. At that time, she was diagnosed with fluid
overload and a questionable pneumonia. She was treated with
three days of levofloxacin which was discontinued prematurely
secondary to the side effects of diarrhea.
Since her discharge, the patient continued with hemodialysis
three times per week at [**Hospital1 1474**] where she had been complaint
with hemodialysis sessions. Her last hemodialysis was two
days prior to arrival when she had a hypertensive episode
during the [**Hospital1 2286**] (her blood pressure at that time was
unknown and the amount of fluid taken off was also unknown).
The daughter reports that the patient has had a history of
hypertension during hemodialysis in the past; more than six
months ago. She has a history of poor compliance with fluid
restriction. In addition to her shortness of breath, she
also complained of lightheadedness when changing position.
On the morning of admission, she sat up on the edge of her
bed and fell onto a soft carpet hitting her face. She denied
loss of consciousness.
REVIEW OF SYSTEMS: Review of systems was positive for
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
an occasional productive cough of yellow sputum, and
lightheadedness. Review of systems was negative for chest
pain, diaphoresis, neck or arm pain, or dysuria (she has
oliguria). Review of systems was also negative for fevers,
chills, nausea, vomiting, visual changes, or weight loss.
In the Emergency Department, on [**8-28**], the patient was
seen by the Renal Service in consultation who felt she should
be transferred to the Medical Intensive Care Unit for two
liters of ultrafiltration. It was thought she needed
Intensive Care Unit observation secondary to her history of
hypertension during hemodialysis.
In the Emergency Department, the team tried to get a head
computed tomography but the patient was unable to lay flat
secondary to her fluid overload. However, the patient did
not show any neurologic changes at that time.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on hemodialysis on Monday,
Wednesday, and Friday).
2. Chronic obstructive pulmonary disease.
3. Interstitial lung disease (on home oxygen with 2 liters
nasal cannula).
4. Compression fracture.
5. Aortic stenosis with an aortic valve area of 0.6 cm2 and
a peak velocity of 70 mmHg.
6. Paroxysmal atrial fibrillation.
7. History of pericardial effusion.
8. Depression.
9. Status post abdominal aortic aneurysm in [**2159**].
10. Pulmonary artery hypertension; moderate.
11. Echocardiogram on [**8-11**] revealed an ejection
fraction of 60%, 1+ aortic regurgitation, 2+ mitral
regurgitation, and 2+ tricuspid regurgitation.
MEDICATIONS ON ADMISSION:
1. Renagel 800 mg by mouth three times per day
2. Prozac 20 mg by mouth once per day.
3. Fosamax 70 mg by mouth every Monday.
4. Serax 15 mg by mouth q.h.s.
5. Calcium carbonate 1500 mg by mouth once per day.
6. Atenolol 25 mg by mouth once per day.
7. Albuterol as needed.
8. Calcitonin.
9. Atrovent.
10. Dilaudid 2 mg to 4 mg by mouth q.4-6h. as needed.
11. Prednisone taper from her last admission which was
discontinued on [**8-23**].
ALLERGIES: CODEINE (leads to pruritus) and PERCOCET (leads
to nausea).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed her temperature was 97.8 degrees
Fahrenheit, her heart rate was 89, her blood pressure was
147/67, respiratory rate was 20, and her oxygen saturation
was 97% on 4 liters nasal cannula. Generally, the patient
was an elderly woman in mild respiratory distress with the
head of the bed at 30 degrees, using accessory muscles.
Head, eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light. The oropharynx was clear. The mucous
membranes were dry. On neck examination, the patient had
jugular venous distention up to her ears. Lung examination
revealed she had rales bilaterally up to the her apices with
intermittent wheezes at the left upper lobe. Cardiovascular
examination revealed the patient had a [**2-25**] harsh systolic
ejection murmur throughout her precordium which was heard
best at the right upper sternal border with radiation to the
neck. A regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. Normal active bowel sounds.
Extremity examination revealed she had 3+ lower extremity
edema up to the thighs. Some pedal petechiae. An
arteriovenous fistula in her left arm used for hemodialysis.
Neurologic examination revealed the patient was alert and
oriented times three. She moved all extremities. Cranial
nerves II through XII were intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed her white blood cell count was 7.3, her
hematocrit was 36.1, and her platelets were 152. Her sodium
was 132, potassium was 5, chloride was 89, bicarbonate was
32, blood urea nitrogen was 31, creatinine was 4.3, and her
blood glucose was 116. Initial creatine kinase was 14.
Troponin was 0.15.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative for
consolidations or effusions. There was mild edema and
chronic idiopathic fibrotic changes.
Electrocardiogram revealed a normal sinus rhythm, right axis
deviation, normal intervals, with an old right bundle-branch
block pattern. There were old T wave inversions in V1
through V3, and leads III and aVF.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RENAL ISSUES: The patient was admitted to the Medical
Intensive Care Unit for monitoring during ultrafiltration.
On [**8-28**], she had 2.3 liters taken off and she
symptomatically improved in terms of her shortness of breath.
Her lower extremity edema also resolved as well. The
following day she had her regular hemodialysis; at which time
they took off 3 liters, and she continued to feel even better
than her baseline in terms of her breathing.
Her sodium did drop during her admission from 132 to 128.
She was kept on a 1-liter fluid restriction, and the plan was
to undergo one final hemodialysis prior to discharge this
afternoon; and hopefully her hyponatremia will correct.
2. PULMONARY ISSUES: The patient has a long history of
interstitial lung disease and chronic obstructive pulmonary
disease. She was on 2 liters of oxygen at home, and she
remained on this regimen while in house, and her oxygen
saturations remained between 94% and 100%. She felt
symptomatically improved following each hemodialysis session
and reported her breathing was better than her baseline.
3. CARDIOVASCULAR ISSUES: The patient has a long history of
aortic stenosis and was seen by the Cardiology approximately
one year ago; at which time no intervention was felt to be
needed.
However, on a more recent echocardiogram this past [**Month (only) 216**] it
was found that she had severe aortic stenosis with an aortic
valve area of 0.6 cm2.
The Cardiology Service was consulted during this admission to
discuss possible treatment of her aortic stenosis, and it was
felt that due to her comorbidities any operative risks (in
terms of an aortic valve replacement) would be extremely high
and was not an option at this time. They also discussed the
option of a valvuloplasty, which they felt would not be
beneficial in this case.
During this admission, she remained in a normal sinus rhythm.
After her initial hemodialysis, she showed no signs of heart
failure. She did have a recent echocardiogram in [**Month (only) 216**]
which showed an ejection fraction of 60%.
She initially came in on atenolol 25 mg by mouth once per day
which was held secondary to her undergoing hemodialysis
immediately upon admission. Her blood pressure remained
under control throughout this admission, and atenolol was
never given.
On admission, the patient had an elevated troponin of 0.15.
Her cardiac enzymes were cycled. Her creatine kinase levels
remained flat for five cycles. Her troponin increased from
0.15 to a peak of 0.19. It came down again to 0.17. It was
felt that this was likely secondary to the patient renal
failure and did not represent an acute myocardial infarction.
4. STATUS POST FALL ISSUES: The patient had reportedly fell
and hit her head on the carpet on the day of admission. She
had no mental status changes and no overt neurologic changes. A
complete musculoskeletal exam was performed and did not reveal
any abnormalities or injury.
A computed tomography was attempted in the Emergency
Department; however, the patient could not lay down secondary
to her orthopnea. It was decided that unless she were to
develop neurologic changes no imaging would be necessary.
She continued to be neurologically intact and without changes
throughout her hospitalization.
5. CODE STATUS: Code status was discussed with the patient
on admission, and she decided to be do not resuscitate/do not
intubate.
6. DISPOSITION ISSUES: Placement was discussed with the
patient and her daughter, and it was decided that the patient
was unable to care for herself at home and would likely need
at least [**Hospital 3058**] rehabilitation if not [**Hospital 4820**]
rehabilitation.
DISCHARGE DIAGNOSES:
1. End-stage renal disease (on hemodialysis).
2. Severe aortic stenosis.
3. Chronic obstructive pulmonary disease/interstitial lung
disease (on home oxygen).
4. Acute exacerbation of congestive heart failure.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Fosamax 70 mg by mouth every Monday.
3. Oxazepam 15 mg by mouth q.h.s.
4. Atrovent meter-dosed inhaler 2 puffs inhaled four times
per day.
5. Albuterol meter-dosed inhaler 2 puffs inhaled q.6h.
6. Calcium carbonate 1500 mg by mouth once per day.
7. Fluoxetine 20 mg by mouth once per day.
8. Sevelamer 800 mg by mouth three times per day.
9. Albuterol nebulizers q.6h. as needed.
10. Protonix 40 mg by mouth once per day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 105396**]
MEDQUIST36
D: [**2168-8-31**] 12:20
T: [**2168-8-31**] 13:03
JOB#: [**Job Number 105397**]
ICD9 Codes: 4280, 4241, 496, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4622
} | Medical Text: Admission Date: [**2187-10-4**] Discharge Date: [**2187-10-25**]
Date of Birth: [**2127-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Ischemic Right Lower Extremity
Major Surgical or Invasive Procedure:
[**2187-10-5**] Right Below Knee Amputation
[**2187-10-15**] Mitral Valve Replacement utilizing a 27mm St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 9041**] Valve with Repair of Atrial Abscess
[**2187-10-19**] Implantation of Dual Chamber Pacemaker([**Company 1543**]
EnPulse)
History of Present Illness:
Mr. [**Known lastname 15499**] is a 60 year old male with a very complicated past
medical history. He was recently diagonosed with Enterococcal
and Klebsiella bactermia. This was further complicated by
Enterococcal mitral valve endocarditis and septic emboli to
central nervous system, spleen and lungs. Cardiac surgery was
delayed at that time due to increased risk of bleeding secondary
to central nervous system emboli. While undergoing intravenous
antibiotic therapy, he started to experience progressive
symptoms of an ischemic right leg with 4-5 days of purple and
cool right foot with pain on ambulation. He was subsequently
admitted for right below knee amputation.
Past Medical History:
Enterococcal Mitral Valve Endocarditis with Septic Emboli,
Enterococcal and Klebsiella Bacteremia - currently being treated
on admisstion, End Stage Renal Disease - s/p Cadaveric Renal
Transplant in [**2178**] now on Hemodialysis since [**2187-6-23**] - s/p
Right AV Fistula, Coronary Artery Disease with history of silent
MI in [**2185**], Type I Diabetes Mellitus, Peripheral Vascular
Disease - s/p Popliteal-Tibial BPG in [**2184**], Hypertension,
Hypercholesterolemia, Diabetic Retinopathy and Neuropathy,
Neurogenic Bladder with history of frequent UTI - patient self
caths himself daily, Bicuspid Aortic Valve
Social History:
Former smoker. Admits to occasional ETOH. He is divorced with
three children. He is not employed and requires disability.
Family History:
No history of premature coronary artery disease.
Physical Exam:
Vital signs: T 99.4, BP 151/76, HR 72, R 20, SAT 98% on 2L
Gen: alert and oriented x3, no acute distress
Lungs: clear to auscultation bilatrally
Heart: RRR with systolic mumur @ LLSB-apex
Abd: soft nontender, nonstended bowel sounds present. no masses,
no bruits
PVD: rt. leg mottled, cold from below knee to toe. Left foot
warm and pink.
Pulses:rt. fem pulse 2+ absent pulses distally. Left fem p[ulse
2=,absent [**Doctor Last Name **], dopperable pedal pulsed left foot.
Neuro: grossly intact
Pertinent Results:
[**2187-10-5**] 12:00AM BLOOD WBC-11.0 RBC-3.58* Hgb-10.0* Hct-30.5*
MCV-85 MCH-27.9 MCHC-32.7 RDW-18.7* Plt Ct-306
[**2187-10-5**] 12:00AM BLOOD PT-14.0* PTT-30.3 INR(PT)-1.2*
[**2187-10-5**] 12:00AM BLOOD Glucose-282* UreaN-36* Creat-3.7* Na-133
K-4.4 Cl-97 HCO3-28 AnGap-12
[**2187-10-5**] 12:00AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.8
[**2187-10-5**] 12:00AM BLOOD Cyclspr-LESS THAN
[**2187-10-8**] 06:24AM BLOOD Genta-<0.3*
Brief Hospital Course:
Mr. [**Known lastname 15499**] was initially admitted to the Vascular service. The
renal, infectious disease and cardiac surgery services were
subsequently consulted to participate in medical/surgical
management. The day after admission, Mr. [**Known lastname 15499**] [**Last Name (Titles) 1834**] a
right below knee amputation by Dr. [**Last Name (STitle) 1391**] of the Vascular
Service. He tolerated the procedure and there were no
complications. He remained on Ampicillin and Gentamicin for his
MV endocarditis while hemodialysis was continued. The renal
service recommended to discontinue the Cellcept and Cyclosporine
and initiate Prednisone in anticipation of upcoming cardiac
surgery. Cellcept and Cyclosporine will not need to be resumed
in the future as his renal transplant graft has already failed.
Mr. [**Known lastname 15499**] otherwise remained stable on medical therapy.
Further cardiac evaluation included blood and urine cultures
with repeat transthoracic echocardiogram. Blood cultures
remained negative while echocardiogram showed a slightly smaller
mitral valve vegetation(compared to [**2187-8-24**] ECHO) with
moderate to severe mitral regurgitation. Overall left
ventricular function was normal and his aortic valve was
bicuspid. No aortic stenosis or regurgitation was seen. Initial
urine culture revealed yeast. His urine culture cleared
following treatment with Fluconazole. He was eventually cleared
by the ID service to proceed with cardiac surgery. On [**10-15**], Dr. [**Last Name (STitle) **] performed a mitral valve replacement. The
operation was uneventful and he was brought to the CSRU for
invasive monitoring. For further surgical details, please see
seperate dictated operative note. Within 24 hours, he awoke
neurologically intact and was extubated without incident. His
postoperative course was complicated by complete heart block.
The EP service was consulted. His complete heart block persisted
and Mr. [**Known lastname 15499**] eventually [**Known lastname 1834**] placement on permanent
pacemaker on [**10-19**]. He maintained stable hemodynamics and
eventually transferred to the SDU. The [**Last Name (un) **] service was
consulted to assist in the management of his poorly controlled
diabetes mellitus. The ID and renal services continued to follow
him throughout his postoperative course. Antibiotics were
continued and titrated according to levels. He remained on
Prednisone for immunosuppression. Mr. [**Known lastname 15499**] gradually made
clinical improvements and worked with physical and occupational
therapies to improve strength and mobility. He was eventually
cleared for discharge to rehab on postoperative day nine. At
discharge, he will cotinue to require a total of four weeks of
intravenous antibiotics from the date of surgery - last dose
should be on [**2187-11-12**].
Medications on Admission:
Renagel 800 tid, Zetia 10 qd, Lescol 40 qd, Plavix 75 qd,
Protonix 40 qd, Cyclosporine 100 [**Hospital1 **], Cellcept [**Pager number **] [**Hospital1 **], Diovan
160 [**Hospital1 **], Lopressor 50 [**Hospital1 **], Lantus Insulin, Humalog Insulin, IV
Ampicillin, IV Gentamicin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Enterococcal Mitral Valve Endocarditis - s/p MVR, Ischemic Right
Leg - s/p Right BKA, Postoperative Complete Heart Block - s/p
PPM, Preoperative Yeast Urinary Tract Infection, End Stage Renal
Disease - s/p Cadaveric Renal Transplant in [**2178**] now on
Hemodialysis since [**2187-6-23**], Coronary Artery Disease, Diabetes
Mellitus, Peripheral Vascular Disease - s/p Popliteal-Tibial BPG
in [**2184**], Hypertension, Hypercholesterolemia, Diabetic
Retinopathy and Neuropathy, Neurogenic Bladder with history of
frequent UTI
Discharge Condition:
Stable
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Intravenous antibiotics will need to
continue until [**2187-11-12**]. Please monitor Vancomycin and
Gentamicin levels and titrate accordingly.
Followup Instructions:
Cardiac Surgeon, Dr. [**Last Name (STitle) **] in [**3-28**] weeks - call for appt,
([**Telephone/Fax (1) 11763**]
Vascular Surgeon, Dr. [**Last Name (STitle) 1391**] in 3 weeks for staple removal -
call for appt ([**Telephone/Fax (1) 14585**]
Infectious Disease, Dr. [**Last Name (STitle) 3394**] - call for appt ([**Telephone/Fax (1) 6732**]
[**Hospital **] Clinic, Dr. [**Last Name (STitle) **] - call for appt ([**Telephone/Fax (1) 15500**]
Cardiologist, Dr. [**Last Name (STitle) **] in [**1-26**] weeks - call for appt
Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-26**] weeks - call for appt
On Friday and Monday, patient needs a Vanco trough drawn at
hemodialysis just before Vanco is given and then a Vanco peak
taken 1 hour after Vanco is given. Please call results in to
Dr. [**Last Name (STitle) 3394**] at ([**Telephone/Fax (1) 6732**]
Completed by:[**2187-10-25**]
ICD9 Codes: 5856, 4280, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4623
} | Medical Text: Admission Date: [**2186-10-13**] Discharge Date: [**2186-11-10**]
Date of Birth: [**2137-2-18**] Sex: M
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
acute kidney injury
Major Surgical or Invasive Procedure:
[**2186-11-4**]: orthotopic liver transplant
History of Present Illness:
Mr. [**Known lastname **] is a 49 y.o. M with Hep C cirrhosis who presents for
acute renal failure. He had a recent hospitalization at [**Hospital1 18**]
[**Date range (1) 80556**] for renal failure with creatinine of 3.0 on
admission and urine Na<10. Felt to be due to hepatorenal
syndrome due to failed response to fluid challenge. His
diuretics were held and he was treated with octreotide,
midodrine, and albumin. His creatinine improved to 1.5 upon
discharge.
.
He was seen last week by Dr. [**Name (NI) **] and noted to have
increased creatinine to 2.7, as well as new cough with green
mucus and hemoptysis (clots). CXR was normal and he was given
azithromycin. His sx persisted, so he was seen by his VA
provider yesterday, who rx'd him doxycycline. He also had labs
redone this week in [**Location (un) 5583**] that showed further increase in
creatinine (value not available at this time), which prompted
him to be directly admitted from home.
.
On the floor, he notes increased abd soreness from baseline x1
week, worse with deep breath, although not as severe as his
prior SBP. Also notes increased dyspnea from baseline, that he
associates with concurrent abd pain. Has has had poor PO intake
over the past week. Also notes intermittent sore throat, chronic
nausea, chronic diarrhea from lactulose. He denies fever,
chills, night sweats, headache, vision changes, rhinorrhea,
congestion, chest pain, vomiting, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HCV Cirrhosis, genotype 1 (with 3.9 x 2.7 mass in the segment VI
of the liver could be perfusion abnormality versus a hepatoma
seen on [**2185**])
SBP [**6-15**], currently on norfloxacin prophylaxis
Esophageal Varicies (distal) [**12-9**]+ noted [**1-15**] endoscopy at OSH
Depression/Anxiety
Hypertension
h/o infectious colitis [**8-/2184**] to [**12/2184**]
Nephrolithiasis - prior lithiotripsy
Social History:
His HCV thought to be [**1-9**] to occupational exposure, patient used
to work as dialysis nurse and had a needle stick. Past alcohol
use described as occasional wine/cocktail, has not drunk since
[**2175**]. He is an ex-cigarette smoker for the last eight years, but
prior to this has a 20-pack year history. Denies any illicit
drug use, marijuana, intravenous drug use, tattoos, or body
piercing. He is married with two children.
Family History:
He has one brother who has genetic hemochromatosis. He has one
sister with thyroid disease and diabetes, and a second sister
who has cholesterolemia and hypertension. Both of his parents
have had coronary artery disease. His mother succumbed to
complications of her coronary artery disease.
Physical Exam:
Vitals - T: 97.3 BP: 124/71 HR: 73 RR: 16 02 sat: 95RA UOP 1090
GENERAL: Well appearing, NAD
HEENT: No icterus, MM dry, neck supple
CARDIAC: RRR no m/r/g
LUNG: CTAB, except slight crackles at right base
ABDOMEN: Soft, distended with ascites. Nontender. +fluid wave.
No organomegaly. NABS.
EXT: 1+ ankle edema. WWP.
NEURO: A+Ox3. CN 2-12 grossly intact. No asterixis.
Pertinent Results:
On Admission: [**2186-10-14**]
WBC-5.3# RBC-2.51* Hgb-8.5* Hct-25.0* MCV-100* MCH-33.8*
MCHC-33.9 RDW-17.6* Plt Ct-59*
PT-21.4* PTT-59.4* INR(PT)-2.0*
Glucose-86 UreaN-46* Creat-3.5* Na-135 K-4.2 Cl-112* HCO3-17*
AnGap-10
ALT-33 AST-55* LD(LDH)-174 AlkPhos-93 TotBili-3.9*
Albumin-2.1* Calcium-8.0* Phos-3.8 Mg-2.3
On Discharge: [**2186-11-10**]
WBC-4.3 RBC-3.19* Hgb-10.0* Hct-27.4* MCV-86 MCH-31.3 MCHC-36.4*
RDW-17.5* Plt Ct-38*
PT-12.7 PTT-26.4 INR(PT)-1.1
Glucose-84 UreaN-59* Creat-2.1* Na-137 K-3.1* Cl-103 HCO3-26
AnGap-11
ALT-63* AST-31 AlkPhos-32* TotBili-1.2 Albumin-3.4
Calcium-8.7 Phos-3.8 Mg-1.8
tacroFK-4.8*
Brief Hospital Course:
[**Last Name (un) **]: Creatinine decreased to 2.4. Upon discharge in [**8-16**], was
1.5. Urine Na was less than 10 now 17. Concerning for HRS
physiology. s/p blood transfusion. Currently on daily midodrine
and octreotide. Anti-GBM negative. Good UOP and high blood
pressures. He was diagnosed with a UTI pre surgery. The UA is
consistent with infection. Treated with CTX. Received a seven
day course .
Confusion: This is new as of [**2186-10-31**]. Concern for
encephalopathy and asterixis. He was placed on lactulose and
rifaxamin until the time of the liver transplant.
.
HCV Cirrhosis: MELD on admission was 36. H/o decompensation with
SBP, encephalopathy, varices, ascites and thrombocytopenia. Para
negative for SBP this admission.
The patient stayed hospitalized until the time of his liver
transplant due to his decompensation.
On [**2186-11-4**] the patient received and orthotopic liver
transplant. He was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He
received routine induction immunosuppresion to include cellcept,
solumedrol with taper and prograf which was started on the
evening of POD 0. The surgery went well with the only issue
recorded as the bile ducts were taken down and re-anastomosed
due to evidence of a bile leak. In the post op period the drain
output was minimal and the lateral drain was d/c'd prior to
discharge.
His LFTs never really were elevated and his creatinine came down
to 2.1 by day of discharge and his urine output was excellent
between one and two liters.
POD 1 ultrasound was WNL
His prograf was dose adjusted daily based on trough levels. The
level was initially high in the mid teens. Labs will be
recehecked Monday [**11-13**].
He was ambulating without difficulty although he had c/o pitting
leg edema for which he received IV lasix with good response. He
will go home on 20 PO daily x three days with re-assessment in
clinic of his fluid status. Patient was reminded to only use the
lasix for the three days to avoid dehydration.
He was tolerating diet and using supplements PRN.
He was not sent on insulin as blood sugars were never elevated
and fasting levels were excellent.
Medications on Admission:
Lactulose 30 mL po QID
Midodrine 5 mg po TID
Nadolol 10 mg po daily (held per Dr. [**Name (STitle) 23173**])
Norfloxacin 400 mg po daily
Phytonadione 5 mg po daily
Potassium Chloride SR 20 meq po daily
Sertraline 50 mg po daily
Doxycycline 100mg daily x10 days (started [**10-12**])
Motrin prn
Benadryl prn
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Follow transplant clinic taper.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA & Hospice Services
Discharge Diagnosis:
s/p liver transplant
Hepatorenal syndrome with acute kidney failure: resolved
Discharge Condition:
Stable
Ambulatory
A+Ox3
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, yellowing of skin or eyes, or other concerning
symptoms.
Drain and record JP bulb output three times daily and more often
as necessary. Bring copy of record with you to transplant clinic
appointments. Place a new drain sponge around the drain site
daily and as needed.
Please call the transplant clinic if the drain output increases
significantly, turns bloody, green or develops a foul odor.
Drink enough fluids to keep your urine light yellow in color
Monitor the incision for redness, drainage or bleeding. [**Month (only) 116**]
leave the incision open to air.
You may shower. Pat incision dry and place a new drain sponge
daily
No heavy lifting
No driving if taking narcotic pain medication. Driving should
only be resumed with your surgeons permission
Labs every Monday and Thursday at [**Hospital **] Medical Office Building
Lab
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-11-17**] 1:50
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2186-11-17**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-11-24**] 12:50
Completed by:[**2186-11-10**]
ICD9 Codes: 5849, 5990, 5715, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4624
} | Medical Text: Admission Date: [**2173-12-18**] Discharge Date: [**2173-12-18**]
Date of Birth: [**2150-11-4**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
EtOH Intoxication
Major Surgical or Invasive Procedure:
Invasive Intubation
History of Present Illness:
20 y/o healthy male who was out drinking with friends,
reportedly consumed 8 shots of tequila and one bottle of
champagne and passed out on the couch when his friends noted
that he was very somnolent and not very rousable. Friends called
EMS. Initial vitals were T:98, BP:100/P, HR:100, RR:18 and FSG
was 119. Patient was intubated on arrival to [**Hospital1 18**] ED for airway
protection as was vomiting with high concern for inability to
protect his airway given altered conciousness. Patient received
Etomidate 20 mg and Succinylcholine 120 mg prior to intubation.
He also received 2.5L NS and had 500 cc UOP in ED. Vitals prior
to transfer were BP:109/79, HR:82, and SO2:100%.
.
ROS unable to obtain. Pt intubated with Propofol running, on AC,
appears comfortable.
Past Medical History:
Past Medical History: Per mother, no major medical problems, no
daily meds, no hospitalizations, no surgeries
Social History:
Social History: [**University/College 5130**] student, also works part-time in
the pathology department at [**Hospital1 3278**], where his uncle or cousin is
[**Name2 (NI) **] of medical students. His mother was very surprised with
this presentation and says it's very unusual for him; that he
does drink but never had this dramatic a presentation. She
denies cigarettes or drugs.
Family History:
Unremarkable per mother
Physical Exam:
Physical Exam:
95.2 86/43 81 99% 14
Intubated and sedated, not responding to sternal rub, no
apparent trauma. Appears healthy young man
Pinpoint pupils
CTAB no w/c/r/r
RRR no m/g
Abd soft NT ND
No BLE edema
Pertinent Results:
[**2173-12-18**] 06:17AM URINE HOURS-RANDOM
[**2173-12-18**] 06:17AM URINE GR HOLD-HOLD
[**2173-12-18**] 05:25AM TYPE-ART RATES-14/ TIDAL VOL-550 PEEP-5 O2-40
PO2-231* PCO2-37 PH-7.35 TOTAL CO2-21 BASE XS--4 -ASSIST/CON
INTUBATED-INTUBATED
[**2173-12-18**] 05:06AM URINE HOURS-RANDOM
[**2173-12-18**] 05:06AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2173-12-18**] 01:17AM TYPE-ART RATES-[**2-28**] PO2-81* PCO2-44 PH-7.32*
TOTAL CO2-24 BASE XS--3 -ASSIST/CON INTUBATED-INTUBATED
[**2173-12-17**] 11:55PM GLUCOSE-118* UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-3.1* CHLORIDE-100 TOTAL CO2-20* ANION GAP-19
[**2173-12-17**] 11:55PM estGFR-Using this
[**2173-12-17**] 11:55PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2173-12-17**] 11:55PM ASA-NEG ETHANOL-376* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-12-17**] 11:55PM WBC-11.5* RBC-5.20 HGB-15.9 HCT-44.5 MCV-86
MCH-30.6 MCHC-35.8* RDW-13.8
[**2173-12-17**] 11:55PM NEUTS-52.0 LYMPHS-41.4 MONOS-4.5 EOS-1.1
BASOS-1.1
[**2173-12-17**] 11:55PM PLT COUNT-274
[**2173-12-17**] 11:55PM PT-13.3 PTT-25.5 INR(PT)-1.1
HEAD CT
FINDINGS: There is no evidence of acute intracranial hemorrhage,
acute major
vascular territory infarction, shift of normally midline
structures, discrete
masses, or mass effect. The ventricles and sulci are normal in
size and
configuration. The visualized osseous structures appear grossly
unremarkable.
Visualized paranasal sinuses and mastoid air cells appear clear.
IMPRESSION: No acute intracranial process.
CXR
HISTORY: ET tube placement.
FINDINGS: In comparison with the earlier study of this date, the
endotracheal
tube tip now measures approximately 3 cm above the carina. No
change in the
appearance of the heart and lungs.
Brief Hospital Course:
20yo healthy M with acute alcohol intoxication, intubated for
airway protection.
.
1. EtOH intoxication: With level 376. Intubated for airway
protection. Serum tox and urine tox both negative suggesting
against other toxin ingestion. Extubated the following morning
without complications.
.
2. Leukocytosis: Suspect acute stress reaction. No fevers. Not
treated with antibiotics. Can follow up as an outpatient.
3. Acidosis: Suspected mixed acute respiratory and metabolic.
Suspect some element of hypoventilation and anion accumulation,
both due to intoxication. Lactate not elevated. Extubated with
no evidence of metabolic acidosis.
.
4. Hypotension: SBP's in the 90's on arrival to [**Hospital Unit Name 153**], responding
already to fluid bolus. Suspect Propofol induced after
intubation. BP's normalized by next morning.
.
5. Dispo: Patient does not have PCP. [**Name10 (NameIs) **] following up
with [**Hospital 5130**] Health Care facility, or given Number for [**Company 191**]
facility to set up an outpatient appointment.
Medications on Admission:
None per pt's mom
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Intubation for airway protection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Be sure to maintain oral hydration and eat appropriate, balanced
meals.
You were admitted to [**Hospital1 69**] after
you were found unresponsive due to alcohol intoxication. While
you were in the ED, you were vomiting and intubated for airway
protection. When you awoke, we extubated you without any
difficulties. You had no other symptoms and your lab values were
reassuring, therefore we are discharging you in stable condition
to follow up with your primary care doctor. Please be more
careful if you decide to drink alcohol in the future.
No changes were made to your medication regimen.
Followup Instructions:
Please follow up with the [**Hospital 5130**] Health Care facility, or
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17316**] or any of the residents at the [**Company 191**] Clniic
at [**Hospital1 18**] ([**Telephone/Fax (1) 250**])
ICD9 Codes: 2762, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4625
} | Medical Text: Admission Date: [**2197-8-3**] Discharge Date: [**2197-8-11**]
Date of Birth: [**2123-9-15**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 73-year-old gentleman
who is status post prostate surgery at an outside hospital in
[**2197-5-16**] who was transferred to [**Hospital1 190**] with diaphoresis and electrocardiogram changes
with elevated cardiac enzymes. He denied chest pain or
shortness of breath at that time. He had a catheterization
which showed 3-vessel disease. He reports some shortness of
breath with walking up stairs since that time - relieved with
sublingual nitroglycerin.
Cardiac catheterization on [**2197-5-30**] revealed a right-
dominant system, left main coronary artery patent with mild
diffuse disease, left anterior descending 70 to 80 percent,
left circumflex 60 to 70 percent, right coronary artery
occluded with integrated flow, right-to-left collaterals, and
moderately elevated left ventricular end-diastolic pressure.
Cardiac echocardiogram on [**2197-5-30**] revealed right atrium
mildly dilated, ejection fraction of 20 to 25 percent, aortic
root moderately dilated, mild 1 plus aortic insufficiency, 1
to 2 plus mitral regurgitation, 1 plus tricuspid
regurgitation, and left ventricle severely depressed with
global hypokinesis.
At that time, he was referred coronary artery bypass
grafting. He returned to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in the office
before coming into the hospital on [**2197-8-3**] for
coronary artery bypass grafting surgery.
PAST MEDICAL HISTORY: Coronary artery disease (status post
myocardial infarction in [**2197-5-16**]), gastrointestinal
bleed in [**2197-5-16**] (status post endoscopy which revealed
severe duodenal ulcerations), congestive heart failure
without rheumatic fever in [**2152**], diabetic neuropathy, with
chronic renal insufficiency (baseline creatinine of 2.6), non-
insulin-dependent diabetes, hypertension, hyperlipidemia,
prostate cancer, history of [**Female First Name (un) 564**] esophagitis, right eye
blindness, and a History of transurethral resection of the
prostate on [**2197-5-26**].
MEDICATIONS ON ADMISSION: Allopurinol 100 mg by mouth once
per day, lisinopril 5 mg by mouth once per day, Lipitor 40 mg
by mouth once per day, Isordil 30 mg by mouth once per day,
amiodarone 200 mg by mouth once per day, Protonix 40 mg by
mouth once per day, Aspirin 325 mg by mouth once per day,
Amaryl 2 mg by mouth every morning, multivitamin, Toprol 100
mg by mouth once per day, Lasix 20 mg by mouth once per day,
Detrol 4 mg by mouth once per day, and Paxil 40 mg by mouth
once per day.
ALLERGIES: PENICILLIN (causes a rash).
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his heart rate was 60 in a normal sinus rhythm, blood
pressure was on the right was 98/70 and on the left was
98/72, his height was 5 feet 8 inches tall, and his weight
was 160 pounds. In general, the patient was in no acute
distress. He appeared slightly younger than his stated age.
Skin was warm and dry. No rashes, eczema, or psoriasis.
Head, eyes, ears, nose, and throat examination revealed the
pupils were equal, round, and reactive to light. The
extraocular movements were intact. Poor dentition. The neck
was supple. There was no lymphadenopathy. There were no
thyroid masses. The lungs were clear to auscultation
bilaterally. Heart was regular in rate and rhythm. First
heart sounds and second heart sounds. No murmurs, rubs, or
gallops. The abdomen was soft, nontender, and nondistended.
There were positive bowel sounds. Extremities revealed no
calf tenderness. No edema. No cyanosis or erythema. No
varicosities. Neurologic examination revealed cranial nerves
II through XII were intact. Normal sensory. No motor
deficits. Alert and oriented times three.
PERTINENT LABORATORY DATA PRIOR TO SURGERY: White blood cell
count was 6.1, his hematocrit was 33.2, and his platelets
were 155. Prothrombin time was 12.7, partial thromboplastin
time was 30.4, and his INR was 1. Glucose was 126, blood
urea nitrogen was 48, creatinine was 2.1, sodium was 144,
potassium was 4.5, chloride was 110, and bicarbonate was 25.
Alanine-aminotransferase was 60, aspartate aminotransferase
was 32, lactate dehydrogenase was 156, alkaline phosphatase
was 90, amylase was 53, and total bilirubin was 0.4. Albumin
was 4.1. Calcium was 9.6, phosphorous was 3.2, and magnesium
was 1.3. Hemoglobin A1C was 6.1. Urinalysis was negative.
RADIOLOGY: A chest x-ray revealed heart size was within
normal limits. The lungs were clear. No pulmonary edema.
No pleural effusions. No evidence of an acute
cardiopulmonary process.
SUMMARY OF HOSPITAL COURSE: The patient presented to the
hospital on [**2197-8-3**]. He was prepared for coronary
artery bypass grafting. In the Operating Room, a Foley
catheter was unable to be placed by Cardiothoracic Surgery.
Urology was called, and they were able to place a Foley
catheter with flexible cystoscopy and wire.
The patient then proceeded with coronary artery bypass
grafting times two by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with a LIMA to the
LAD and saphenous vein graft to the OM. Cardiopulmonary
bypass time was 57 minutes. Cross-clamp time was 36 minutes.
Mean arterial pressure after surgery was 82. CVP was 13, PAD
was 16. A-paced at 84 beats per minute with Neo-Synephrine
and propofol titrated to affect. He continued to be A-paced
throughout the night after surgery with an underlying sinus
bradycardia. On the morning on postoperative day one, he was
extubated and weaned off his Neo-Synephrine.
He was transferred to the Inpatient Recovery Unit on
postoperative day two. On postoperative day three, he began
having episodes of atrial fibrillation that continued
throughout his hospital stay with an Electrophysiology
evaluation. He was started on amiodarone and Lopressor for
rate control. He was not started on Coumadin secondary to
preoperative melena with duodenal ulceration disease by
scope. Electrophysiology recommendations also included [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] of Hearts monitor and followup as an outpatient.
Other inpatient issues included inability to put a Foley
catheter in prior to surgery. Per Urology recommendations,
his catheter stayed in until postoperative day four. When it
was removed, he had no trouble passing urine and returning to
his baseline continence. He will follow up with his
outpatient personal urologist.
A further issue included a baseline diagnosis of diabetes
with increased fingerstick blood sugars postoperatively, for
which [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained. They added a daily
Lantus dose to his regimen and increased - actually doubled -
his by mouth Amaryl dose. The patient does check his
fingerstick blood sugars twice per day at home. He was given
teaching on injections and visiting nurse as well with help
him injection teaching at home.
The patient was followed by Physical Therapy throughout his
hospital stay. On [**2197-8-10**] the patient was found to
be safe for home. He continued with decreased cadence, a
wide-based gait, and decreased trunk stay; however, he was
able to walk a total distance of 300 feet and go up and down
15 steps independently.
DISCHARGE DISPOSITION: He was discharged home on [**2197-8-11**] with visiting nurses to follow.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times two.
2. Urinary retention.
3. Benign prostatic hypertrophy.
4. Postoperative atrial fibrillation.
5. Type 2 diabetes.
6. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Percocet 5/325 one to two tablets by mouth q.4-6h. as
needed.
3. Aspirin 325 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Lasix 20 mg by mouth twice per day (for seven days).
6. Lipitor 40 mg by mouth once per day.
7. Allopurinol 100 mg by mouth once per day.
8. Vitamin C 500 mg by mouth twice per day.
9. Polysaccharide-Iron Complex 150 mg by mouth once per day.
10. Multivitamin by mouth every day.
11. Paxil 40 mg by mouth once per day.
12. Glimepiride 2 mg by mouth twice per day.
13. Lopressor 50 mg by mouth twice per day.
14. Amiodarone 400 mg by mouth once per day for 14 days
followed by amiodarone 200 mg by mouth once per day for
five weeks.
15. Lantus insulin 8 units subcutaneously at hour of
sleep.
16. Lisinopril 5 mg by mouth once per day.
17. Potassium chloride 20 mEq by mouth twice per day
(for seven days).
DISCHARGE FOLLOWUP: Visiting nurse to follow the patient at
home. Appointment with Dr. [**Last Name (STitle) **] in one to two weeks.
Appointment with Dr. [**First Name (STitle) **] in two to three weeks.
Appointment with Dr. [**Last Name (STitle) 70**] in six weeks. Discharged home
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to be followed by primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2197-8-10**] 18:32:40
T: [**2197-8-10**] 20:15:40
Job#: [**Job Number 55523**]
ICD9 Codes: 9971, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4626
} | Medical Text: Admission Date: [**2173-2-2**] Discharge Date: [**2173-2-22**]
Date of Birth: [**2135-2-18**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Fever, confusion.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old man
with HIV aids, last CD4 count of 22, viral load greater than
750 ......./ml, who is a patient at [**Hospital6 **]
and was referred for admission for fevers and anemia.
It was reported that he had been doing poorly times four
weeks with complaints of fatigue and intermittent diarrhea
since [**Month (only) 1096**]. The fevers began during the first week of
[**Month (only) 404**] with a temperature as high as 104??????. He reported at
that time that he never fully defervesced. His temperature
waxed and waned with severe night sweats, chills, headache
and intermittent photophobia.
The patient also noted watery-brown diarrhea occurring over
the past month, as well as nausea and poor p.o. intake. He
was recently seen by his primary care physician who took
stool cultures. At that time, he was started on Flagyl
empirically for belly pain and diarrhea, but he had to stop
after three doses because of an anaphylactic reaction
requiring Benadryl and steroids in the Emergency Department
on [**2173-1-27**].
The patient presented to his primary care physician's office
on the day of admission because of significant temperatures,
as well as having hallucinations, "seeing fairies on the edge
of his bed," on the morning of admission.
PAST MEDICAL HISTORY: 1. HIV aids times 15 years. The
patient reported poor compliance of his antiretrovirals
secondary to intolerance from side affects. He most recently
was on therapy ................ two weeks prior to admission
when they were stopped for concerns of side affects versus
infection causing the fevers and diarrhea. 2. PCP pneumonia
in [**2171-7-31**], thrush [**2170**]. 3. Anxiety disorder. 4.
Pancytopenia felt secondary to HIV disease. He denied prior
blood transfusions. Per his primary care physician, [**Name10 (NameIs) **]
anemia improved with HAA-RT therapy.
MEDICATIONS ON ADMISSION: Azithromycin, Bactrim, Epivir
.................., Ativan p.r.n. anxiety, Celexa.
ALLERGIES: PENICILLIN CAUSING ANAPHYLAXIS, FLAGYL CAUSING
ANAPHYLAXIS (THE PATIENT ALSO HAD TAKEN TWO DOSES OF
CIPROFLOXACIN WITH THE FLAGYL PRIOR TO HIS ANAPHYLACTIC
REACTION).
FAMILY HISTORY: Maternal aunt and uncle who both reported
died secondary to intracranial aneurysmal bleeds.
SOCIAL HISTORY: No tobacco. No alcohol. The patient as
living alone prior this hospitalization; however, he plans to
move in with his partner. His proxy to his healthcare is
mother, [**Name (NI) **] [**Name (NI) 5025**]. Family is very important to him.
PHYSICAL EXAMINATION: Vital signs: Temperature 103??????, blood
pressure 97/58, pulse 116, respirations 16, oxygen saturation
98% on room air, without ambulatory desaturation per primary
care physician, [**Name Initial (NameIs) 4977**] 172 lbs. General: The patient was a
pleasant, thin, young man in no acute distress. He was
conversing fluently and appropriately. HEENT: Pupils equal,
round and reactive to light. Extraocular movements intact.
Sclerae anicteric. Oropharynx clear. Chest: Clear to
auscultation bilaterally. No wheezes, rhonchi or rales.
Cardiovascular: Tachycardiac, regular rhythm. Normal S1 and
S2. Positive S3 gallop. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: No
edema. Neurological: Alert and oriented. Cranial nerves
II-XII intact. Strength 5 out of 5 times four extremities.
Sensation intact to light touch.
LABORATORY DATA: White count 2.2, hematocrit 22.2, platelet
count 94, differential 26% neutrophils, 7% bands, 56% lymphs,
5% monos; PT 13.3, INR 1.2, PTT 35.9; of note, baseline
hematocrit 22-26; sodium 137, potassium 3.7, chloride 105,
bicarb 24, BUN 11, creatinine 0.7; ALT 62, AST 60, LD 550,
...... phos 123, amylase 76, lipase 33, total bilirubin 0.3,
calcium 8.1, phosphate 3.0, magnesium 1.6, albumin 30.1.
HOSPITAL COURSE: The patient was admitted to the General
Medicine Service for further work-up of his fevers and
diarrhea.
1. Infectious disease: In the Emergency Room, the patient
was evaluated first for acute meningitis with lumbar puncture
demonstrating 0-1 white cells, greater than 100,000 red blood
cells, no xanthochromia, protein 256, glucose 47, with
negative gram stain, no polys.
Throat cultures all eventually proved no growth to date, as
well as blood and urine cultures which were unremarkable.
The patient received a single dose of Vancomycin empirically
prior to return of CSF results. Of note, the patient
improved with Vancomycin and fluids.
The patient underwent further work-up for possible source of
infection including full-body scan which was negative for
abscess and unremarkable for lymphadenopathy. His blood
cultures including microcytics continued to be no growth
date. His urine cultures and urinalysis were unremarkable.
His chest x-ray was negative for pneumonia. Induced sputums
were negative for PCP and acid fast bacilli.
The patient underwent further evaluation of his abdomen given
his diarrhea complaints including full set of stool cultures
sent times three which were unremarkable, as well as a
colonic biopsy, including testing for CMV which was again
unremarkable.
The patient's stool viral culture was notable for a positive
adenovirus. The patient continued to be febrile, spiking
temperatures to 103?????? without clear source. Eventually
send-out lab results came back demonstrating a positive urine
histologic antigen.
On [**2-19**], the patient commenced treatment for
histoplasmosis including ................. 3 mg/kg/day,
pretreatment Tylenol, Benadryl, and 500 cc normal saline.
The patient tolerated this treatment well with good response
including complete defervescence.
The patient will continue to complete a 14-day course of
.................. with Itraconazole to be followed. The
patient's dose and course length of treatment of Itraconazole
will be determined by his primary care physician, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**] in consult with Infectious Disease Service here at
[**Hospital3 **].
Of note, the patient's stool was determined to be positive
for adenovirus, as well as possible nasopharyngeal swab
confirming the presence of adenovirus. Treatment was
considered for this finding, especially given the patient's
new cardiomyopathy; however, given the potential renal
toxicity of treatment, the decision was made to hold on
treatment at this time with further follow-up with the
patient's primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**], to determine
if treatment in the future is necessary.
2. Neurologic: The patient's confusion persisted throughout
the first two weeks of hospitalization correlating well with
his temperature spikes. He was without hallucinations
throughout his hospital stay. The source of his mental
status changes was felt likely to be ...................
given his infectious source. However, he was also evaluated
for possible HIV encephalopathy, including a lumbar puncture
to test for CSF HIV viral load which demonstrated 6230
...../ml. The case was discussed with Dr. .................
who felt that the elevated viral load in CSF would be
consistent with HIV encephalopathy.
At the time of discharge, he further had CSF TP, PCR and VDRL
pending. Note, serum RPR was negative.
The patient is to follow-up with Dr. ................... in
his clinic with instructions to make an appointment,
[**Telephone/Fax (1) 2343**], for further evaluation.
3. Heme: The patient had persistent pancytopenia requiring
multiple blood transfusions throughout his hospitalization.
He tolerated these without difficulty and had good
symptomatic relief and improvement in his low blood pressure.
The likely source of his pancytopenia is bone marrow
involvement from his HIV disease. Given his long history of
pancytopenia, he will be restarted on ...............
therapy, which has had good result in the past with his blood
count monitored.
This dictation is to be continued.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8184**], M.D. [**MD Number(1) 8185**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2173-2-22**] 11:37
T: [**2173-2-22**] 12:06
JOB#: [**Job Number 35377**]
ICD9 Codes: 4280, 2761, 4254, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4627
} | Medical Text: Admission Date: [**2172-9-12**] Discharge Date: [**2172-9-15**]
Date of Birth: [**2146-9-27**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This is a 25-year-old gentleman
who is status post a motor vehicle accident in which he was
the unrestrained driver and struck a telephone pole. He was
ejected from the car and landed on his face. Extreme damage
was reported to the vehicle by first responders. It was
presumed high-speed motor vehicle collision.
The patient was med-flighted to [**Hospital1 188**], and he was intubated upon arrival in the Emergency
Department. After initial trauma assessment and initiation
of resuscitation, a CT scan was performed. Images of his
head, abdomen, and thorax were obtained. His injuries
included bilateral zygomal and orbital rim fractures, a right
temporal fracture, bilateral frontal contusions, and a right
temporal epidural versus subdural hematoma. The anterior and
posterior of the frontal sinus was fractured with
communication with the ethmoid air cells, presumably caused
air in the orbit.
PAST MEDICAL HISTORY: Denies.
PAST SURGICAL HISTORY: Denies.
SOCIAL HISTORY: Denies.
ALLERGIES: Denies.
MEDICATIONS ON ADMISSION: Denies.
PHYSICAL EXAMINATION ON PRESENTATION: Initial examination
revealed the patient had a heart rate in the 80s, with a
blood pressure of 150/80s. He was intubated with multiple
abrasions, and severe swelling and contusions of his face.
He was not following commands. His [**Location (un) 2611**] Coma Scale
was 16. His pupils were reactive on the right going from
3 mm to 2 mm of light. The response was brisk. On the left,
his pupils went from 2.5 mm to 2 mm, also brisk. Initial
evaluation revealed corticate posturing was noted by the
trauma team. He withdrew equally and purposefully after 20
minutes in the trauma bay. He withdrew to noxious stimuli
equally and purposefully after 20 minutes in the trauma bay.
HOSPITAL COURSE BY SYSTEM:
1. NEUROLOGY: Mr. [**Known lastname 4553**] was transported to Intensive
Care Unit from the trauma bay. Upon arrival, Neurosurgery
promptly placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bolt. This allowed continuous
monitoring of intracranial pressure. Notably, intracranial
pressure was 17 when the bolt was placed.
During his hospitalization, his intracranial pressure was
monitored very closely and maintained to a level of less than
20. To do this, mannitol 25 mg q.6h. was used. While using
mannitol, his serum osmolalities were followed closely. In
addition, to monitoring his intracranial pressure, his
systemic blood pressures were maintained in such a manner
that his cerebral perfusion pressure was maintained at
70 mmHg. A parameter monitor for his neurologic status PaCO2
which was maintained between 35 and 40 during his
hospitalization.
Mr. [**Known lastname 4553**] was kept sedated with propofol and was given
Fentanyl and/or morphine boluses for pain. Neurologic checks
were followed initially every one hour and then every two
hours to monitor for change in neurologic examination.
During his hospitalization, two subsequent CAT scans were
obtained; one on hospital day two. This CAT scan revealed
possible worsening and was read as epidural versus subdural
bleed. After a discussion with both Radiology and
Neurosurgery, the decision was made that the worsening did
not appear significant, and this was not accompanied by a
change in his clinical condition. His intracranial pressure
remained stable, and his clinical examination was unchanged.
An additional CT scan was obtained on hospital day three.
This examination was unchanged from the previous examination.
Again, his intracranial pressure and neurologic examination
remained the same, and conservative treatment was opted for.
2. CARDIOVASCULAR: As described in previous section,
Neo-Synephrine and eventually Levophed were used to maintain
a coronary perfusion pressure of greater than 70. A
pulmonary artery catheter was placed on hospital day four.
This catheter was placed when the patient started to
demonstrate septic physiology and for increasing pressor
support. Please see Infectious Disease section for more
details.
3. GASTROINTESTINAL: Mr. [**Known lastname 4553**] was n.p.o. from the time
of his admission. A orogastric tube was passed. Initially
during admission, carafate was given down the orogastric
tube. However, on a routine chest x-ray shot on hospital day
three, a mediastinum was noted. This raised the question of
potential esophageal rupture. Gastroenterology was consulted
for this.
Gastroenterology was consulted to assist in creating the most
appropriate diagnostic rhythm given his intubated and sedated
status. At this point, his carafate was switched to
intravenous Protonix and he was strictly n.p.o.
4. HEMATOLOGY: Throughout Mr. [**Known lastname **] admission, his
hematocrit remained stable in the low 30s. As will be
discussed in the Infectious Disease section, he developed an
episode of what appeared to be sepsis, and his white blood
cell count peaked at 23. Mr. [**Known lastname 4553**] was on Pneumo boots
spontaneous compression devices for deep venous thrombosis
prophylaxis. He was not a candidate for subcutaneous heparin
as we were concerned of an intracranial hemorrhage. An
inferior vena cava filter was considered but was deferred, as
it was felt that Mr. [**Known lastname 4553**] was too unstable to undergo the
procedure.
5. ENDOCRINE: Mr. [**Last Name (Titles) 42740**] blood sugar was maintained
under tight control from 100 to 130 using a regular insulin
sliding-scale.
6. INFECTIOUS DISEASE: Mr. [**Known lastname 4553**] had a spike in white
blood cell count and developed fevers. His blood urine and
sputum were all cultured. Blood cultures were pertinent for
one bottle of gram-positive coagulase-negative Staphylococcus
which grew from [**9-13**]. His preliminary cultures including
sputum from [**9-13**] grew Escherichia coli. Sputum from
[**9-15**] grew gram-negative rods, not yet speciated, and from
[**9-15**] a bronchoalveolar lavage grew 1+ gram-negative rods
and 4+ polymorphonuclear lymphocytes.
Throughout this time, Mr. [**Known lastname **] temperature continued to
increase and was such that on hospital day four, his
temperature maximum was 42.2 degrees centigrade. During his
hospitalization, his was treated with vancomycin for his
gram-negative rods, imipenem, and Flagyl. Initially, he had
been placed on clindamycin to cover his drain, but his
cultures became positive, and his white blood cell count
increased. He was switched from clindamycin to the imipenem
and Flagyl. Vancomycin was added when we had the positive
blood culture.
With a fever of 102, up to 42 degrees centigrade, aggressive
measures including cooling blankets, alcohol swabs, and fans
were used in an attempt to bring his body temperature down.
Hypercarbia would result and increase in cerebral perfusion,
paralysis was initiated to decrease genesis of carbon dioxide
secreted during shivering.
7. PULMONARY: As discussed in the Infectious Disease
section, Mr. [**Known lastname 4553**] developed a pneumonia likely from
gram-negative organisms, but most likely from Escherichia
coli. For this pneumonia, he was placed empirically on
imipenem, vancomycin, and Flagyl.
On hospital day three, Mr. [**Known lastname 4553**] had developed an episode
of tachycardia and tachypnea. For this, a CT angiogram was
obtained which demonstrated no pulmonary embolism.
On hospital day four, a routine chest x-ray revealed a
left-sided pneumothorax. For this, a left #34 French chest
tube was placed. On the evening of hospital day four,
Mr. [**Known lastname 4553**] had an acute episode whereby his central venous
pressure rose sharply and immediately followed by a period of
asystole. Urgent resuscitation measures were initiated. The
measures included attempts at pacing. Epinephrine and
atropine were administered as were bicarbonate and calcium.
He had a differential diagnosis of asystole preceded by an
acute rise in central venous pressure included attention
pneumothorax, cardiac tamponade, and pulmonary embolism.
During the resuscitation afterwards, it was noted that a
patent left chest tube was present in the left chest, so
initially neo-decompression was attempted in the right chest.
There was no sign of attention pneumothorax with
decompression, and a right chest tube was placed. During
this time, a needle aspiration of what was felt to be the
pericardium was performed revealing bloody fluid coming back.
A left anterior thoracotomy was made by the Cardiac Surgery
fellow who was present.
After 30 minutes of active resuscitation including internal
cardiac massage, there was no evidence of return of vital
signs or electric activity to the heart as noted on
electrocardiogram monitors. Resuscitation was terminated at
[**2084**] on [**9-15**]. After the termination of resuscitation,
both the anesthesia Intensive Care Unit attending and the
surgical attending were present to discuss the proceedings
events with the patient's family members including his next
of [**Doctor First Name **], his mother. Permission for a postmortem examination
was granted.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2172-9-16**] 00:21
T: [**2172-9-22**] 11:11
JOB#: [**Job Number 38168**]
ICD9 Codes: 4275, 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4628
} | Medical Text: Admission Date: [**2134-5-6**] Discharge Date: [**2134-6-6**]
Date of Birth: [**2058-2-27**] Sex: M
Service: MEDICINE
Allergies:
Nadolol / Propranolol / Lidocaine Hcl/Epinephrine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Central Venous Line Placement
Arterial Line Placement
Intubation
Mechanical Intubation
Tracheostomy
Lumbar Puncture
Temporary hemodialysis catheter placement
History of Present Illness:
Mr. [**Known lastname 80259**] is a 76M with DM and cirrhosis who presented to an
OSH on [**5-3**] with 3d of lethargy, headache, and diarrhea. Patient
was reportedly well until the week prior to transfer when he
developed a watery diarrhea. Family noticed that he seemed to be
more lethargic toward the end of the week. Over the weekend,
complained of a frontal headache -- intense, unusual for him.
His headache worsened over the weekend and by [**5-3**] was severe.
Family noticed that gait was abnormal and he was "shuffling." He
felt shaky and cold, and had difficulty standing. At that point,
wife brought him to another hospital. No travel or known sick
contacts, but he had eaten a cheese/seafood dish which was
unusual for him. No n/v, abdominal pain, melena, hematochezia,
neck stiffness, photophobia, chest discomfort, dyspnea, dysuria.
Denies any travel.
.
At the OSH, empiric ceftriaxone, vancomycin, flagyl, and
acyclovir were initiated upon admission. His respiratory status
remained poor. He was intubated due to respiratory distress the
morning of [**5-4**]. He was started on pressors and admitted to the
CCU. Blood cultures subsequently grew out listeria, and
ampicillin was initiated on [**5-4**], ceftriaxone was continued.
.
Hemodynamically he improved and neosynephrine was weaned off by
[**5-6**] AM. Hospital course notable for Cr rise to 3.3, and
elevation of transaminases to 1000s. He underwent a paracentesis
on [**5-5**] with removal of 900cc of fluid. Albumin was initiated at
25mg [**Hospital1 **]. He was also found to have a troponin elevation to 17,
and echocardiogram showed an EF depressed to 15%. His mental
status remained poor. No LP was done. CXR and CT head were
apparently unremarkable, CT abdomen on admission showed ascites.
.
Given deteriorating liver and kidney function transferred to
[**Hospital1 18**] for further workup.
Past Medical History:
Crytogenic cirrhosis ?[**1-25**] NASH - Grade 2 varices s/p banding.
h/o hypotension with betablockers
DM
Diverticulosis
HTN
Hyperlipidemia
Chronic low back pain
s/p appendectomy
s/p tonsillectomy
h/o L hydrocele repair
+PPD
Social History:
Married. Former smoker, h/o heavy EtoH. Per d/w son he is still
drinking fairly regularly.
Family History:
no liver disease
Physical Exam:
Vitals 97.2 96 107/80 19 98% on PSV
HEENT conjugate gaze, PEARL, +scleral icterus
Neck supple
CV regular s1 s2 no m/r/g
Pulm lungs clear bilaterally
Abd soft nontender +bowel sounds no hsm
Extrem feet cool with diminished pulses, cyanotic however radial
pulses are palpable. dopplerable L PT, R PT and DP. 1+ edema
Neuro intubated and sedated. PEARL. toes downgoing bilaterally.
Derm jaundiced no rash
Lines/tubes/drains R groin line without exudate or erythema
Pertinent Results:
ADMISSION LABS
[**2134-5-6**] 09:30PM WBC-10.9# RBC-5.01 HGB-12.9* HCT-38.9*
MCV-78* MCH-25.8* MCHC-33.2 RDW-17.1*
[**2134-5-6**] 09:30PM NEUTS-89.8* LYMPHS-5.7* MONOS-4.1 EOS-0.1
BASOS-0.3
[**2134-5-6**] 09:30PM PLT SMR-VERY LOW PLT COUNT-74*
[**2134-5-6**] 09:30PM PT-24.3* PTT-44.1* INR(PT)-2.4*
[**2134-5-6**] 09:30PM ALT(SGPT)-1050* AST(SGOT)-[**2118**]* ALK PHOS-93
TOT BILI-2.9* DIR BILI-1.9* INDIR BIL-1.0
[**2134-5-6**] 09:30PM CALCIUM-8.0* PHOSPHATE-7.6* MAGNESIUM-2.4
[**2134-5-6**] 09:30PM GLUCOSE-140* UREA N-84* CREAT-4.2*#
SODIUM-135 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-10* ANION
GAP-27*
[**2134-5-6**] 09:36PM LACTATE-6.1*
[**2134-5-6**] 09:36PM TYPE-[**Last Name (un) **] PO2-183* PCO2-26* PH-7.22* TOTAL
CO2-11* BASE XS--15 COMMENTS-GREEN-TOP
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] on [**2134-5-7**] with lethargy,
headache, diarrhea, and confusion.
OSH COURSE:
He originally presented to an OSH on [**5-3**] with 3 days of these
symptoms. He had developed watery diarrhea 1 week prior to
transfer to [**Hospital1 18**]. His family noted that his gait was abnormal
and "shuffling." At OSH, empiric ceftriaxone, vancomycin,
Flagyl, and acyclovir were initiated upon admission. He was
intubated due to poor respiratory status on [**2134-5-4**] at OSH. He
was started on pressors and admitted to the CCU. Blood cultures
subsequently grew out listeria, and ampicillin was initiated on
[**2134-5-4**]. Ceftriaxone was continued. Hemodynamically, he
improved at OSH, and neo synephrine was weaned off by [**2134-5-6**]
AM; however, his Cr rose to 3.3 and transaminitis to 1000s. 900
cc Para on [**2134-5-5**]. Troponin elevated to 17 and echo showed
depressed EF of 15%. Mental status remained poor. No LP was
done. CT on admission with ascites. Given deteriorating liver
and kidney function, he was transferred to [**Hospital1 18**] on [**2134-5-7**].
[**Hospital 18**] HOSPITAL COURSE:
# Pulm: The patient remained intubated and on mechanical
ventilation while at [**Hospital1 18**]. During his hospitalization, his
course was complicated by aspiration pneumonia, which was
treated with antibiotics. He ultimately had a tracheostomy.
# ID: The patient's listeriosis was treated with ampicillin and
bactrim for prolonged course. Infectious disease was consulted
and helped in management of his antibiotics. MRI showed small
abscesses in his brain and signals consistent with
cerebritis/meningitis. On [**2134-5-25**], his blood cultures grew out
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**]. All of his lines were cultured and resited.
These line cultures also grew out yeast. He was treated for
fungemia. TTE was negative for vegetations. LP was performed
by IR on [**2134-5-31**] thus far with unrevealing results. He was on
antibiotics for the duration of his hospitalization until CMO
status was decided.
# Renal: Renal assisted in management of his acute renal
failure, which was thought to be due to ATN. The patient had
temporary HD lines placed for CVVH. He continued on CVVH while
hospitalized.
# CV: Patient noted to have troponin leak which was likely
demand ischemia in the setting of acute illness rather than a
primary plaque rupture event. Cardiology was initially
consulted. The patient's troponins were trended.
# Neuro: During his hospitalization, his neurological status was
complicated by seizures which were likely due to small abscesses
[**1-25**] his infection. Neurology was consulted and assisted in
management of his anti-epileptic medication. Additionally, EEGs
were performed which showed moderate diffuse cerebral
dysfunction.
# GI: Liver team consulted due to transamnitis likely in the
setting of sepsis. Trended LFTs daily. Held spirinolactone.
The patient expired on [**2134-6-6**] at 0115 with family at bedside
after having been made comfort measures only. Primary cause of
death due to sepsis secondary to listeriosis and fungemia.
Medications on Admission:
Home:
HCTZ 25mg daily
Metformin 1000mg [**Hospital1 **]
Omeprazole 40mg [**Hospital1 **]
Spironolactone 25mg TID
Cholestyramine 4g daily
Ursodiol 500mg [**Hospital1 **]
Ferrous sulfate 325mg daily
MVT
Fish oil tablets
.
Albumin 50g IV BID
ampicillin 2g Iv q8h
ceftriaxone 1g [**Hospital1 **]
protonix 40 IV BID
lactulose 30mL q8h
aspirin 81mg daily
meoprolol 2.5mg IV q6h
combivent prn
humalog insulin sliding scale
dulcolax, zofran, albututerol, dulcolax prn
Discharge Medications:
None - Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis secondary to listeriosis and fungemia
2. Aspiration pneumonia
3. Seizures
4. Anuric Renal Failure
Secondary Diagnosis:
1. Diabetes
2. Alcoholic Cirrhosis
Discharge Condition:
Expired
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2134-6-6**]
ICD9 Codes: 5845, 5070, 2762, 2851, 4019, 2724, 4280, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4629
} | Medical Text: Admission Date: [**2139-9-29**] Discharge Date: [**2139-10-10**]
Date of Birth: [**2069-5-26**] Sex: F
Service: MEDICINE
Allergies:
Rofecoxib / Percocet / Albuterol / Shellfish
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
# Bilateral lower extremity edema
Major Surgical or Invasive Procedure:
# Tunneled dialysis catheter
History of Present Illness:
70F h/o CRI (Cr 1.7-2.3), uterine cancer s/p XRT c/b proctitis,
s/p diverting colostomy c/b GIB, PCM, CAD s/p CABG/PCI,
hypersensitivity pneumonitis [**2-6**] possible psittacosis, admitted
for increased bilateral lower extremity edema.
Pt had been previously admitted 1 month ago for afib management
and was started on quinidine as renal function did not allow for
initiation of dofetilide. Outpatient furosemide 120mg TID had
been stopped during that admission, then restarted at 120mg
daily. Weight increased from 219 to 236 pounds, with worsening
leg swelling and dyspnea on exertion. Outpatient labs revelead
worsened renal function, with last Cr=3.3 four days prior to
this admission.
.
On ROS, pt denied any interval chest pain, although did
experience palpitations with chronic afib, and denied any
infectious symptomatology.
Past Medical History:
Uterine cancer- s/p XRT '[**34**]
Radiation proctitis s/p diverting colostomy [**2-9**]
GIB [**2-6**] hematochezia from radiation proctitis
Hyperlipidemia
HTN
DM type 2
CAD s/p CABG '[**35**], multiple cardiac catheterizations with PCIs
Sternal MRSA infection s/p debridement x 3
GERD
s/p appy/ccy
CHF with EF>55%
Atrial fibriilation
s/p pacemaker
CRI baseline creatinine 2.0
Social History:
Lives with daughter and son in law, widowed several years ago,
denies T/A/D.
Family History:
Father passed away in 50's from CAD. Siblings with early CAD
Physical Exam:
VS: Temp 98.6, BP 160/D, HR 66, RR 18, O2 sat 99% on 2.5L NC
Gen: pleasant, elderly female in NAD, speaks in full sentences
HEENT: anicteric, obese face [**2-6**] prednisone per pt
Neck: thick supple, JVP 10cm, but difficult to visualize well
Resp: CTA b/l, no wheezes, no appreciable crackles, but
difficult [**2-6**] habitus
CV: irreg, no m/r/g. s/p sternotomy and no sternum
Abd: stoma in place, old scars, non tender, no hsm
Extr: 3+ edema b/l halfway up to knees, tr pulses
Pertinent Results:
Labs:
[**2139-9-30**] 12:00AM GLUCOSE-168* UREA N-92* CREAT-2.8*#
SODIUM-139 POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-36* ANION GAP-14
[**2139-9-30**] 12:00AM ALT(SGPT)-29 AST(SGOT)-16 ALK PHOS-53 TOT
BILI-0.4
[**2139-9-30**] 12:00AM proBNP-4556*
[**2139-9-30**] 12:00AM ALBUMIN-3.3* CALCIUM-9.2 PHOSPHATE-3.9
MAGNESIUM-2.4
[**2139-9-30**] 12:00AM TSH-1.3
[**2139-9-30**] 12:00AM WBC-7.0 RBC-3.42* HGB-11.0* HCT-32.5* MCV-95
MCH-32.2* MCHC-34.0 RDW-15.7*
[**2139-9-30**] 12:00AM NEUTS-85.6* LYMPHS-8.4* MONOS-5.0 EOS-0.8
BASOS-0.2
[**2139-9-30**] 12:00AM PLT COUNT-190
[**2139-9-30**] 12:00AM PT-11.4 PTT-20.0* INR(PT)-1.0
[**2139-10-9**] 04:01AM BLOOD WBC-15.6*# RBC-3.21* Hgb-10.4* Hct-31.0*
MCV-97 MCH-32.5* MCHC-33.6 RDW-16.2* Plt Ct-205
[**2139-10-8**] 02:46PM BLOOD PT-10.5 INR(PT)-0.9
[**2139-10-9**] 04:01AM BLOOD Glucose-165* UreaN-95* Creat-3.5* Na-137
K-5.3* Cl-94* HCO3-33* AnGap-15
[**2139-10-9**] 04:01AM BLOOD CK(CPK)-99
[**2139-10-8**] 09:08PM BLOOD CK(CPK)-87
[**2139-10-8**] 02:06PM BLOOD CK(CPK)-86
[**2139-10-8**] 10:31AM BLOOD CK(CPK)-61
[**2139-10-9**] 04:01AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2139-10-8**] 09:08PM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-8381*
[**2139-10-8**] 02:06PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2139-10-8**] 10:31AM BLOOD CK-MB-2 cTropnT-0.06*
[**2139-10-9**] 04:01AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.0
[**2139-10-8**] 09:08PM BLOOD calTIBC-333 Ferritn-224* TRF-256
[**2139-10-9**] 01:19PM BLOOD PTH-260*
[**2139-10-8**] 03:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2139-10-9**] 02:36AM BLOOD Digoxin-2.1*
[**2139-10-8**] 03:00PM BLOOD HCV Ab-NEGATIVE
[**2139-10-8**] 07:16PM BLOOD Type-ART Temp-35.4 Rates-/22 FiO2-50
pO2-92 pCO2-52* pH-7.40 calTCO2-33* Base XS-5 Intubat-NOT INTUBA
Comment-VENTIMASK
[**2139-10-8**] 03:29PM BLOOD Type-[**Last Name (un) **] Temp-35.8 Rates-/25 pO2-40*
pCO2-83* pH-7.28* calTCO2-41* Base XS-8 Intubat-NOT INTUBA
Vent-SPONTANEOU
.
Micro:
URINE CULTURE (Final [**2139-10-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
AEROBIC BOTTLE (Final [**2139-10-14**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2139-10-14**]): NO GROWTH.
.
[**2139-10-8**] 10:09 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2139-10-12**]**
GRAM STAIN (Final [**2139-10-9**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2139-10-12**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
.
Imaging:
.
CHEST (PA & LAT) [**2139-9-30**] 10:18 AM
IMPRESSION:
1) Stable, moderate pulmonary edema.
2) Stable cardiomegaly.
.
ECHO [**9-30**]:
Suboptimal image quality. The left atrium is mildly dilated. The
right atrium is moderately dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
distal septal and apical akinesis suggested. The inferior wall
is not well seen. Overall left ventricular systolic function is
probably preserved (LVEF 50%). There is no ventricular septal
defect. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. An eccentric, posteriorly
directed jet of mild to moderate ([**1-6**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
If clinically indicated, a repeat study with contrast (Definity)
may aid in regional LV systolic function determination.
.
UNILAT LOWER EXT VEINS LEFT [**2139-10-6**] 9:01 AM
IMPRESSION:
1. No deep venous thrombosis in left common femoral, superficial
femoral, or popliteal veins.
2. 3.4-cm septated fluid collection corresponding to the
palpable abnormality in the left lateral ankle, a finding that
is of uncertain significance but could represent hematoma,
synovial cyst or infectious collection, among other entities.
.
CHEST (PA & LAT) [**2139-10-7**] 11:52 PM
IMPRESSION: PA and lateral chest compared to [**9-30**]
through earlier in the day:
Pulmonary and mediastinal vascular congestion have worsened
today consistent with cardiac decompensation though moderate
cardiomegaly is unchanged and there is no pulmonary edema or
pleural effusion. There are no focal abnormalities in the lungs
to suggest pneumonia. Transvenous right atrial and right
ventricular pacer leads in standard placements.
.
CHEST (PA & LAT) [**2139-10-7**] 1:52 PM
FINDINGS: In comparison with the study of [**9-30**], there is little
change. Again there is some enlargement of the cardiac
silhouette with fullness of the pulmonary vessels and a
dual-lead pacemaker device in place. No evidence of acute
pneumonia.
.
CT CHEST W/O CONTRAST [**2139-10-8**] 8:21 PM
IMPRESSION:
1. Left upper lobe and lingular pneumonia. Multiple small
peribronchial nodules likely from chronic small airways disease.
Follow up imaging after treatment is recommended to document
resolution and follow up nodules.
2. Evaluation for pulmonary embolism is not possible on this
noncontrast study, and if clincally indicated, VQ scan would be
helpful for further evaluation. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**2139-10-8**].
3. Asbestos related pleural disease.
4. Multinodular thyroid with calcifications. Clinical
correlation with labs and ultrasound recommended.
.
CHEST (PORTABLE AP) [**2139-10-8**] 11:00 AM
Portable AP chest radiograph was reviewed. The patient head
overlie the lung apices, thus evaluation of pneumothorax cannot
be obtained precisely, although no evidence of large
pneumothorax is present. The PermCath catheter can be visualized
up to cavoatrial junction. The cardiac size is mildly enlarged
but unchanged compared to [**2139-10-7**]. Two pacemaker leads
terminate in right atrium and right ventricle. Repeated
radiograph with improved technique is highly recommended.
Brief Hospital Course:
70F h/o DM2, atrial fibrillation, CAD s/p CABG, CHF (EF 45-50%),
and CRI with volume overload. Her diuretic regimen was titrated
while on the floor with good response initially, but she
continued to have worsening renal failure. Renal was consulted
and after several days of trying to diurese, she was taken to
get a tunneled catheter placed. In the PACU, she was unable to
lie down flat because of respiratory discomfort. She was
therefore consented to suspend her DNI status for intubation to
place the tunneled catheter. She was extubated with difficulty
after the procedure and suffered desaturations and delirium.
Her oxygen saturation recovered, but she was transferred to the
MICU given her tenuous respiratory status. She was given HD in
the MICU as is her course on the general medicine floor.
.
# Possible acute diastolic CHF exacerbation - cardiac vs renal
in etiology. Most likely the volume overload initially related
to the decreased dose of her diuretics. Concerning increase in
Cr reported from outside labs, pt continues to make good urine
according to patient, obstruction seems unlikely. Her diuretic
regimen was titrated and while her Cr worsened. HD was
considered the eventual endpoint of her disease. She suffered
worsening pulmonary edema in the days before the tunneled
catheter was placed and she was nearing HD.
.
# Respiratory distress: Patient experienced acute respiratory
decompensation in the PACU, and was noted to vomit while supine.
During that time, patient was also noted to be hypertensive
with EKG changes suspicious for ischemia, giving rise to the
suspicion that patient possibly experienced acute diastolic
failure leading to pulmonary edema. Because of the acuity of
patient's respiratory compromise, PE was also suspected. CTA
was considered but given patient's renal function, this was
deferred. Subsequent bilateral LENIs were negative, and CT w/o
contrast demonstrated extensive LUL and LLL infiltrate.
Follow-up sputum Gram stain demonstrated Gram-positive rods and
cocci, as well as Gram-negative rods. Acute desaturation was
therefore considered likely triggered by mucus plugging [**2-6**]
hospital-acquired PNA (although pt was chronically on prednisone
25mg daily [**2-6**] presumed psittacosis without Bactrim ppx, her
desaturation was considered unlikely related to PCP). Patient
therefore received extensive chest PT and BiPAP with good
effect, and started vancomycin/cefepime/ciprofloxacin. Because
little fluid was removed via HD ultrafiltration, chronic
diastolic dysfunction was considered to be a less likely
contributor. Because of pt's vomiting, pt was also noted to be
at risk for possible aspiration pneumonitis or PNA.
.
# Acute-on-chronic renal failure: As above for the floor. In
the MICU, patient underwent hemodialysis with removal of
approximately 500 cc. Further ultrafiltration was unable to be
performed given low blood pressures. Upon transfer to the
floor, pt's furosemide was continued given difficulty in
managing outpatient fluid status.
.
# Acute mental status change: Patient was noted to have acute
mental status change upon transfer post-op to the MICU. This
was felt likely [**2-6**] multifactorial contributions from
anesthesia, acute hypoxia and hypercarbia, and infection.
Patient required soft two-point restraints overnight during her
first night in the MICU, but returned to near baseline
subsequently.
.
# CAD s/p CABG: Patient was initially continued on her home
regimen of aspirin, metoprolol, and simvastatin, with no ACE
inhibitors in the setting of her renal dysfunction. During
patient's acute desaturation in the PACU post op, EKGs were
concerning for possible ischemic change given patient's
background of coronary artery disease. Cardiac enzymes were
cycled and were negative, and repeat EKGs showed no significant
change. Cardiology was consulted but had low suspicion that
patient had experienced an acute ischemic event.
.
# Atrial fibrillation: Patient was not anti-coagulated given her
history of hematuria, and was continued on metoprolol and
quinidine for rate control.
.
# DM2: Patient was continued on her home regimen of insulin NPH
[**Hospital1 **] with sliding scale. Her insulin regimen was titrated for
blood sugar control, though her glycemic control proved
difficult.
.
# LLE lesion: Ms. [**Known lastname **] was found to have a painful,
erythematous, floculent nodule on the lateral aspect of her LLE.
An ultrasound showed a fluid collection, but aspiration of the
lesion was unsuccessful. She remained afebrile throughout the
course of this lesion, which lasted roughly a week. The lesion
was stable through that week after its initial presentation.
.
# GERD: Patient was continued on her home regimen of omeprazole.
.
# Hypertension: Patient was continued on her home regimen of
metoprolol.
.
# Hyperlipidemia: Patient was continued on her home regimen of
simvastatin.
.
# Back pain: Patient was continued on home regimen of Vicodin
PRN.
.
Upon transfer from the MICU back to the floor, the patient was
initially respiratorily stable. She was later found in her room
in respiratory arrest followed by ventricular fibrillation.
Given her DNR/DNI status, no efforts were made to resuscitate
her.
Medications on Admission:
Furosemide 120mg daily (from 120mg TID prior to last
hospitalization)
Spironolactone 25mg daily
Metoprolol 100mg TID
[**Known lastname **] 325mg daily
Simvastatin 20mg daily
Prednisone 25mg daily
Omeprazole 20mg daily
Insulin (NPH 40 [**Hospital1 **]), Humalog sliding scale
Iron
Caltrate
Vicodin PRN
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
ventricular fibrillation from respiratory failure
.
Secondary:
Uterine cancer- s/p XRT '[**34**]
Radiation proctitis s/p diverting colostomy [**2-9**]
GIB [**2-6**] hematochezia from radiation proctitis
Hyperlipidemia
HTN
DM type 2
CAD s/p CABG '[**35**], multiple cardiac catheterizations with PCIs
Sternal MRSA infection s/p debridement x 3
GERD
s/p appy/ccy
CHF with EF>55%
Atrial fibriilation
s/p pacemaker
CRI baseline creatinine 2.0
Discharge Condition:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 5849, 4280, 486, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4630
} | Medical Text: Admission Date: [**2113-5-17**] Discharge Date: [**2113-6-22**]
Date of Birth: [**2067-9-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Shortness of breath, altered mental status
Intubated
Major Surgical or Invasive Procedure:
[**2113-5-17**] Ventriculostomy placement
[**2113-5-18**] Cerebral Angiogram
[**2113-5-31**] Tracheostomy
[**2113-6-14**] PEG placement
History of Present Illness:
45yo male with history of IV drug use, endocarditis s/p MVR and
PPM placement, and hepatitis C admitted to OSH with altered
mental status.
.
The patient was admitted to [**Hospital **] Hospital on [**5-4**] requesting
detoxification as he started using IV drugs again. He had not
been compliant with his medications, including his coumadin. He
was found to have a subclavian DVT and a left brachial arterial
aneurysm, which was thought to be secondary to injection of IV
drugs. Vascular evaluated the patient and recommended the
patient be fully sober before any attempt at aneurysm repair.
He was placed on a heparin gtt and transitioned to coumadin. He
had an elevated WBC there and was febrile so he was started in
azithromycin with improvement in both. However, on [**5-8**], he
became agitated and left the hospital AMA. He returned to the
ED on [**5-9**] and reported chest pain radiating to the left arm,
headache, photophobia (no rigidity) and shortness of breath. He
reported using cocaine since his discharge and denied use of
EtOH.
.
While there, he was found to be febrile with increasing
shortness of breath. TTE negative for vegetations and blood
culture with no growth at the time of transfer. CXR with no
clear consolidation and he was scheduled to undergo a TEE to
rule out endocarditis but the patient started withdrawing right
before the procedure. He was given suboxone. Later on during
the hospitalization, he was found to have a dense aphasia and
left hemiplegia. Neurology was consulted and felt this could be
secondary to meningitis vs embolic events. CT scan demonstrated
poor definition of perimesencephalic cisterns without asymmetry
which was concerning for some increased intracranial pressure.
There was evidence of treated AVM with no other signs of acute
or evolving territorial infarct. Patient was started on a
heparin gtt for presumed embolic event.
.
Given the concern for meningitis, he was also treated with
vancomycin, ceftriaxone and gentamycin. His mental status
remained altered. In addition, his respiratory status worsened
requiring intubation on evening [**5-16**]. CXR did not reveal a
clear consolidation and he had elevated A-a gradient so he
underwent a CTA which did not reveal a PE. His mental status
did not improve and his respiratory status worsened. He
continued on a heparin drip. A CTA was negative for PE. He was
intubated and transferred to [**Hospital1 18**] on [**5-17**] for further w/u.
.
On transfer to MICU [**Location (un) 2452**], vital signs were T- 98.2, BP-
127/76, HR- 62, RR- 23, SaO2- 96% (intubated). Patient was
intubated and sedated. On day of admission a new right eye
lateral deviation was noted on exam. Neurosurgery was urgently
consulted. An stat head CT/CTA was obtained that showed SAH and
likely PCA aneurysm.
Past Medical History:
- Streptococcus salivarius mitral valve endocarditis [**9-1**] with
course complicated by severe MR, multiple septic embolic to
bilateral kidneys, spleen, L parietal hemorrhage with underlying
mycotic aneurysm s/p onyx embolization s/p MVR [**2112-2-4**]
- IVDU x 22 yrs (cocaine, oxycodone)
- EtOH Abuse
- hx inguinal hernia repair [**2105**]
- HCV Ab + [**2108**], viral load negative
- Hypertension
- Depression, anxiety
- Permanent pacemaker
Social History:
The patient has a long history of IVDU with cocaine and
oxycodone since the age of 21. He also has a past history of
EtOH abuse. + Tobacco use. He worked as a land-scaper. Was most
recently in rehab, previously lived with his girlfriend
and her children. Pet cats in the home. HIV negative [**9-1**].
Family History:
No family history of coronary artery disease, CVA or malignancy
Physical Exam:
Physical Exam on Admission
Vitals: T- 98.2, BP- 127/76, HR- 62, RR- 23, SaO2- 96%
(intubated).
General: Intubated, sedated
HEENT: Sclera anicteric, pupils reactive to light, non-pinpoint
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, mid-systolic click,
no murmurs
Lungs: Bibasilar crackles (R>L)
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to assess secondary to sedation.
DISCHARGE EXAM:
VS: 98, 146/101, 79, 22, 100% on 50% trach mass
CHEST: clear to auscultation bilaterally
Cardiac: RRR, no MRG
Opens eyes to commands, sitting in chair
Moves right side spontaneously
withdraws from noxioius stimuli on right
Pertinent Results:
Admission Labs:
[**2113-5-17**] 02:15AM PT-23.8* PTT-38.4* INR(PT)-2.3*
[**2113-5-17**] 02:15AM PLT COUNT-423
[**2113-5-17**] 02:15AM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-2.2
[**2113-5-17**] 02:15AM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-2.2
[**2113-5-17**] 02:15AM CK-MB-22* MB INDX-9.0* cTropnT-0.66*
[**2113-5-17**] 02:15AM ALT(SGPT)-31 AST(SGOT)-50* CK(CPK)-244 ALK
PHOS-68 TOT BILI-0.2
[**2113-5-17**] 02:15AM GLUCOSE-122* UREA N-10 CREAT-0.7 SODIUM-133
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-26 ANION GAP-15
[**2113-5-17**] 02:48AM LACTATE-0.8
[**2113-5-17**] 02:48AM TYPE-ART PO2-128* PCO2-35 PH-7.52* TOTAL
CO2-30 BASE XS-6
[**2113-5-17**] 04:14AM URINE RBC->182* WBC-7* BACTERIA-NONE
YEAST-NONE EPI-0
[**2113-5-17**] 04:14AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-5-17**] 04:14AM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2113-5-17**] 10:30AM SED RATE-58*
[**2113-5-17**] 10:34AM PT-19.3* PTT-36.5 INR(PT)-1.8*
[**2113-5-17**] 10:34AM CRP-180.8*
Cardiac labs:
[**2113-5-17**] 02:15AM BLOOD CK-MB-22* MB Indx-9.0* cTropnT-0.66*
[**2113-5-17**] 02:15AM BLOOD ALT-31 AST-50* CK(CPK)-244 AlkPhos-68
TotBili-0.2
[**2113-5-17**] 10:34AM BLOOD CK-MB-19* MB Indx-9.0* cTropnT-0.76*
[**2113-5-17**] 10:34AM BLOOD CK(CPK)-211
[**2113-5-17**] 10:00PM BLOOD CK-MB-8 cTropnT-0.40*
[**2113-5-17**] 10:00PM BLOOD CK(CPK)-93
[**2113-5-18**] 02:15AM BLOOD CK-MB-6 cTropnT-0.39*
[**2113-5-18**] 02:15AM BLOOD ALT-24 AST-27 CK(CPK)-71 AlkPhos-59
TotBili-0.2
[**Hospital3 **]:
[**2113-5-17**] 10:30AM BLOOD ESR-58*
[**2113-5-17**] 10:34AM BLOOD CRP-180.8*
Imaging:
CXR [**5-17**] - FINDINGS: In comparison with the study of [**2112-2-12**],
there is now an endotracheal tube in place, with the tip
approximately 6 cm above the carina. Nasogastric tube is coiled
within the stomach. Pacemaker device remains in place.
Hyperlucency in the upper lungs is again seen consistent with
chronic pulmonary disease. There are some areas of increased
opacification in the bases bilaterally. Some of this most likely
reflects redistribution of blood flow related to the upper zone
emphysema. However, there may be some pulmonary vascular
congestion related to overhydration. In the appropriate clinical
setting, the possibility of supervening pneumonia on one or both
sides would have to be considered.
CT abd/pelv [**5-17**] - IMPRESSION:
1. Compared to prior examination of [**2111-9-20**], there are new
infarcts in the
spleen, right kidney in the lower pole and left kidney in the
upper pole. A new exophytic lesion in the right lower pole is
too small to characterize and while this may represent a cyst,
this could also represent a developing abscess in this clinical
setting. If further differentiation is needed, this could be
performed with MRI.
2. Old infarcts in the spleen and right kidney are again noted.
3. Atelectasis in the lower lobes bilaterally
CTA head [**5-17**] - IMPRESSION:
1. Extensive acute subarachnoid hemorrhage in the basal
cisterns, bilateral sylvian fissures, and left parietal lobe.
Intraventricular extension of hemorrhage with significant
interval increase in size of the ventricles since the earlier
study of [**2113-5-16**].
2. No evidence of diffuse cerebral edema.
3. Known right pontine infarct, with new evolving infarct in the
left
occipital region, may relate to embolization from the aneurysm
of the left
PCA, which may be mycotic.
4. 4-mm aneurysm of the left PCA is new since earlier study of
[**2111-11-5**]
and, in this context, may be mycotic. A "nipple" contour
abnormality in the inferior aspect of the aneurysm, consistent
with the recent rupture.
5. Significant vasospasm involving the mid- through distal
thirds of the
basilar artery, with no appreciable flow seen in the distal
basilar artery.
CT head w/o contrast [**5-17**] - IMPRESSION:
1. Status post placement of right transfrontal ventricular shunt
catheter,
with the tip terminating in the floor of the third ventricle. No
significant short-interval change in the ventricular size.
2. Extensive subarachnoid hemorrhage with intraventricular
extension, stable.
3. Well-defined right pontine hypodensity concerning for
evolving acute
infarction, overall unchanged since the study done today at
12:27 p.m., with evolving left occipital lobe hypodensity,
concerning for an evolving infarct in the setting of left PCA
aneurysm, likely mycotic.
CT head w/o contrast [**5-17**] - IMPRESSION:
1. No significant change from 4:26 p.m.
2. Right frontal approach ventricular shunt tip ends in the
floor of the
third ventricle. No interval change in ventricular size.
3. Unchanged subarachnoid hemorrhage with intraventricular
extension.
4. Unchanged left occipital lobe and right pontine hypodensities
are
concerning for evolving infarctions.
TEE [**5-19**] - No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. A patent foramen ovale
is present. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. A bileaflet
mitral valve prosthesis is present. The motion of the mitral
valve prosthetic leaflets appears normal. The transmitral
gradient is normal for this prosthesis. There is a serpiginous,
highly-mobile echogenic mass, attached to the anterior mitral
sewing ring and prolapsing into the ventricle with each
diastole, through the minor opening of the mechanical
prosthesis. It is most likely a thrombus, although an
atypical-appearing vegetation cannot be excluded. Trivial mitral
regurgitation is seen. The degree of mitral regurgitation seen
is normal for this prosthesis. There is no pericardial effusion.
CT HEAD [**5-19**] IMPRESSION:
1. Status post coiling of left PCA aneurysm and unchanged extent
of
subarachnoid hemorrhage with intraventricular extension.
2. Stable ventriculomegaly with ventriculostomy catheter
unchanged in
position within the third ventricle.
3. Right pontine hypodensity concerning for evolving infarction
but unchanged
from the most recent prior study of [**2113-5-17**].
CTA HEAD [**5-19**] Wet Read:
Wet Read: [**Last Name (un) **] SUN [**2113-5-21**] 5:03 AM
1. Status post coiling of left PCA aneurysm. Subarachnoid
hemorrhage with
intraventricular extension again noted.
2. Stable ventriculomegaly with right frontal approach
ventriculostomy
catheter unchanged in position within the third ventricle.
3. Right pontine hypodensity concerning for evolving infarction
but unchanged from the most recent prior study of [**2113-5-17**].
Hypodensitiy in left occipital region.
4. Dominant left vertebral artery and a hypoplastic right
vertebral artery.
5. No definite flow limiting stenosis or aneurysm > 3 mm in the
carotids and their major branches. ? basilar spasm, similar to
prior exam.
reformats pending.
TCD [**2113-5-20**]
Mildly abnormal TCD evaluation. Above normal
velocities were seen in the left ACA. This may be due to focal
atherosclerotic stenosis, hyperemia, or could be a precursor to
vasospasm. There was no evidence of vasospasm in any vessel.
Recommend repeat TCD exam on [**2113-5-22**].
TCD [**2113-5-23**]
Abnormal TCD evaluation. Mildly increased velocities
in the left MCA were either due to mild vasospasm or hyperemia.
Above normal velocities were seen in the right MCA and the left
ACA. Recommend repeat TCD exam on [**2113-5-24**].
ECHO [**2113-5-24**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
distal inferior/infero-lateral walls only (clips 2 and 42) .
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. A bileaflet mitral
valve prosthesis is present. The motion of the mitral valve
prosthetic leaflets appears normal. The transmitral gradient is
normal for this prosthesis. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild focal systolic left ventricular dysfunction.
Well functioning mechanical mitral valve prosthesis. Moderate
pulmonary artery systolic hypertension.
CTA [**2113-5-24**]: IMPRESSION:
1. Improved caliber of bilateral middle cerebral arteries, when
compared to recent CTA of [**2113-5-21**], but persistently narrowed
compared to remote prior CTA of [**2111-11-5**].
2. Mild persistent narrowing of the A1 segment of both ACAs,
right greater
than the left, and both proximal A2 segments, consistent with
persistent or recurrent vasospasm. Mild persistent narrowing of
the distal basilar artery and its branches, status post balloon
angioplasty, may also represent recurrent vasospasm.
3. Stable hypoattenuating regions in the right paramedian pons
and left
occipital pole, consistent with evolving subacute infarctions.
Stable
encephalomalacia in the left parietal region with associated
embolization
material, unchanged from [**2111**].
4. Stable ventriculomegaly, with unchanged position of external
ventricular drain in the third ventricle via right frontal burr
hole.
5. Status post coiling of the left PCA aneurysm with
intraventricular
hemorrhage, unchanged from [**2113-5-22**]. No evidence of new
hemorrhage is
detected.
TCD [**2113-5-25**]
Mildly abnormal TCD evaluation. Above normal
velocities of the right proximal MCA. No vasospasm was seen in
any vessel. Recommend repeat TCD exam on [**2113-5-26**].
HEAD CT [**2113-5-25**]: IMPRESSION:
1. Small subdural hematoma along right frontal convexity is new
from the most recent prior study of [**2113-5-24**].
2. Decreased ventriculomegaly with slightly decreased
intraventricular
hemorrhage from [**2113-5-24**] and unchanged position of right
transfrontal EVD in the third ventricle.
3. Diffuse loss of [**Doctor Last Name 352**]-white matter differentiation consistent
with cerebral edema appears more pronounced in the left frontal
lobe. Attention is recommended on followup.
4. Stable hypoattenuating areas in the right paramedian pons,
right medial
temporal lobe, and left occipital pole are consistent with
evolving subacute infarctions.
5. Unchanged encephalomalacia in the left parietal region with
associated
embolization material, stable since [**2111**].
TCD [**2113-5-26**]
Abnormal TCD evaluation. Mild vasospasm was seen in
the right proximal MCA. This represents worsening compared with
TCD results from [**2113-5-25**]. Insonation of the left MCA was
technically limited
[**2113-5-26**] CXR
NG tube tip is in the stomach, is coiled, and the tip is at the
fundus. ET
tube is in standard position. Spacer leads are in standard
position with tips in the right atrium and right ventricle.
There is no evident pneumothorax. Patient has known emphysema.
Bibasilar opacities have increased on the left. These are
probably due to increasing atelectasis, but aspiration cannot be
excluded. There is no pleural effusion. Cardiac size is normal.
[**2113-5-26**] CTA head
1. Improved caliber of basilar artery when compared to the
recent CTA of
[**2113-5-24**].
2. Moderate vasospasm of the M1 segment of the left MCA greater
than the
right MCA, increased from [**2113-5-24**].
3. Mild persistent narrowing of the A1 and proximal A2 segments
of the
bilateral ACAs, unchanged from [**2113-5-24**].
4. Stable hypoattenuating regions in the right paramedian pons,
right medial
temporal lobe and left occipital pole, consistent with subacute
infarctions.
5. Stable encephalomalacia in the left parietal region with
embolization
material, unchanged from [**2111**].
6. Status post coiling of left PCA aneurysm with stable
intraventricular
hemorrhage, but no residual subarachnoid hemorrhage. No new
hemorrhage
detected.
[**2113-5-27**] CXR
Compared to the study from the prior day there is no significant
interval
change.
[**2113-5-28**] ECG
Sinus rhythm. Probable prior inferior wall myocardial
infarction. Slight
persistent ST segment elevation in the inferior leads which
could be
consistent with an aneurysm or ongoing ischemia. Slight ST
segment depression in leads VI-V3 suggestive of reciprocal
posterior ischemia. Compared to the previous tracing of [**2113-5-24**]
overall extensive ST segment elevations in the inferior leads
and ST segment depressions in the anterior leads have decreased
suggestive of ongoing infarction. Clinical correlation is
suggested.
[**2113-5-29**] CXR
As compared to the previous radiograph, there is no relevant
change. The pre-existing parenchymal opacity in the retrocardiac
lung areas is likely to be atelectatic, given the concomitant
elevation of the left hemidiaphragm. The presence of a minimal
left pleural effusion cannot be excluded.
No other parenchymal abnormalities, except for the
hyperlucencies in the lung apices, strongly indicative of
extensive pulmonary emphysema.
Normal size of the cardiac silhouette. Unchanged position of the
monitoring and support devices.
[**2113-5-31**] CXR
Comparison is made with prior study [**5-30**].
Cardiomediastinal contours are normal. Patient has known
emphysema. Left
lower lobe retrocardiac atelectasis is unchanged. There are no
new lung
abnormalities, pneumothorax or pleural effusion. Lines and tubes
are in
standard position.
CT head [**2113-5-31**]
1. Right transfrontal EVD, unchanged in position, with unchanged
size of
ventricles from [**2113-5-26**].
2. Residual intraventricular hemorrhage, slightly decreased in
amount
compared to prior studies.
3. Status post coiling of left PCA aneurysm with no residual
subarachnoid
hemorrhage.
4. No new intracranial hemorrhage.
5. Stable subacute infarctions of the right paramedian pons,
right medial
temporal lobe, and small infarct of the left occipital pole.
6. Left parietal encephalomalacia with embolization material,
unchanged from [**2111**].
CXR [**2113-6-1**]
Compared to the previous radiograph, the Dobbhoff catheter has
been
advanced by approximately 5 cm. The tip now projects over the
proximal parts of the stomach. There is no evidence of
complications. The other monitoring and support devices, and the
general appearance of the lung and heart are unchanged.
CXR [**2113-6-2**]: unchanged
CT head [**2113-6-2**]: Stable
CXR [**2113-6-3**]: New linear opacities have developed in the right
mid and both lower lungs, most consistent with areas of
subsegmental atelectasis. Otherwise, no relevant change since
the recent study.
CXR [**2113-6-5**]:
As compared to previous radiograph, small atelectasis at the
upper
aspect of the middle lobe is completely resolved. Normal
appearance of the lung parenchyma, except for the known areas of
hyperlucency in both lung apices. Normal appearance of the
cardiac silhouette. Normal hilar and mediastinal structures.
CXR [**6-7**]: New opacification at the lung bases, confluent on the
left, is probably due to atelectasis, conceivably attributable
to aspiration. Hyperlucent upper lungs indicate emphysema.
Heart is normal, but increased since [**6-5**] suggesting cardiac
decompensation and some early edema in the lower lungs.
Tracheostomy tube in standard placement. Transvenous right
atrial and right ventricular leads in standard placements.
Nasogastric feeding tube ends in the upper
stomach. No pneumothorax. Left jugular line ends in the upper
SVC.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2113-6-8**] 3:41
AM
FINDINGS: As compared to the previous image, the tracheostomy
tube and the other monitoring and support devices are constant.
There are unchanged hyperlucencies in the lung apices,
indicative of severe pulmonary emphysema. The crowded
parenchyma at the lung bases is constant. Unchanged
retrocardiac atelectasis and borderline size of the cardiac
silhouette. No other changes.
CXR [**2113-6-9**]
1. No pneumothorax. Increased left lower lobe collapse and
right basilar
atelectasis.
2. Pneumoperitoneum consistent with recent VP shunt placement.
Head CT [**2113-6-9**]
1. Persistent ventriculomegaly after replacement of the EVD
with a VP shunt along with transependymal CSF migration
consistent with hydrocephalus.
2. Otherwise, stable appearance from the prior study, seven
days ago. No
evidence of new infarction or hemorrhage.
CXR [**2113-6-10**]
Right middle and lower lobe atelectasis have worsened. There is
no good
evidence for pneumonia. Left lower lobe collapse has improved,
but
atelectasis is still substantial. Upper lungs are clear. No
appreciable
pleural effusion or pneumothorax. Presumed shunt catheter
traverses the right neck, chest and upper abdomen. Tracheostomy
tube and left internal jugular line, as well as transvenous
right atrium and right ventricular pacer leads are in standard
placements. A feeding tube ends in the upper stomach. Heart
size is normal.
[**2113-6-13**] PICC line placement - Uncomplicated ultrasound and
fluoroscopically guided double lumen Preliminary ReportPower
PICC line placement via the right basilar venous approach. Final
Preliminary Reportinternal length is 42 cm, with the tip
positioned in the lower SVC. The line Preliminary Reportis ready
to use.
.
[**2113-6-22**]
[**2113-6-22**] 05:10AM BLOOD WBC-7.3 RBC-3.27* Hgb-8.9* Hct-28.6*
MCV-87 MCH-27.2 MCHC-31.1 RDW-14.9 Plt Ct-384
[**2113-6-17**] 05:12PM BLOOD Neuts-73.0* Lymphs-18.2 Monos-7.6 Eos-0.8
Baso-0.4
[**2113-6-22**] 05:10AM BLOOD Plt Ct-384
[**2113-6-22**] 05:10AM BLOOD PT-12.3 PTT-75.9* INR(PT)-1.1
[**2113-6-22**] 05:10AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-143
K-2.8* Cl-104 HCO3-34* AnGap-8
[**2113-6-22**] 12:27PM BLOOD Na-144 K-3.7 Cl-107
[**2113-6-20**] 06:15AM BLOOD ALT-18 AST-23 LD(LDH)-316* AlkPhos-71
TotBili-0.2
[**2113-6-22**] 05:10AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.0
[**2113-6-20**] 06:15AM BLOOD calTIBC-218* Hapto-<5* Ferritn-99
TRF-168*
[**2113-5-20**] 07:08AM BLOOD Triglyc-87
Brief Hospital Course:
This is a 45-year-old gentleman with history of IV drug use,
MVR, hepatitis C who presents with altered mental status and
hypoxic respiratory distress.
.
# PONTINE INFARCATION AND ICH: The patient presented with
altered mental status, initially concerning for meningitis. He
had aphasia and left hemiplegia at the OSH prior to transfer,
thought to be due to infection. Neurology consult at OSH
recommended stat head CT, which was negative for intracranial
hemorrhage. He was continued on heparin gtt with some
improvement in his symptoms; coumadin was resumed at 15mg daily
at OSH. He was treated with vancomycin and ceftriaxone for
possible meningitis. On [**5-17**] at 1100 he was noticed to have
right eye deviation and to be non-responsive even to pain. Code
Stroke was called. He was found on imaging to have both a
pontine ischemic stroke and small intracranial hemorrhage. The
ischemic stroke may have been due to endocarditis leading to
embolic event, particularly given the patient's open PFO. A
ventricular shunt was placed to reduce ICH, supported by
infusion of protamine and activated factor IX. His mental
status did not substantially improve despite drainage and
normalized ICH. On [**5-20**] the shunt was noted to have clotted off
and TPA was infused to clear it. Also on [**5-20**] CTA revealed
possible vasospasm. The patient's SBP target was increased and
he was transferred to the NeuroICU for further specialized
management. As hospital course progressed, it was determined
that bleeding had stopped and patient was restarted on heparin
drip as bridge to coumadin for mechanical mitral valve. Patient
had a repeat head CT on [**2113-6-20**] that did not show much change.
.
# CEREBRAL SALT WASTING/HYPONATREMIA/FLUDROCORTISONE TAPER:
Patient was started on fludrocortisone taper for cerebral salt
wasting. On [**2113-6-22**], please taper fludrocortisone dose down to
0.1 [**Hospital1 **] for 3 days through [**2113-6-24**]. Then start 0.1QD for 3 days
through [**2113-6-27**]. Then start 0.05mg QD for 3 days through [**2113-6-30**].
Then stop.
.
# ANTIBIOTICS FOR CULTURE NEGATIVE ENDOCARDITIS: Patient
continues on vanc IV 750 mg Q12 and gentamycin 80 Q12 for
endocarditis through [**2113-6-28**]. Patient will need to have
creatinine checked every day. Gentamycin trough should be
checked on [**2113-6-26**] and adjusted accordingly (should be less than
2). Gentamycin is being dosed at 5am and 5pm. If creatinine
rises, gentamycin will need to be adjusted. Please check
vancomycin trough on [**2113-6-26**]. Vancomycin has been dosed at 10am
and 10pm.
.
# HYPOXIC RESPIRATORY FAILURE: The patient's initial
respiratory failure was of unclear etiology, but was thought to
be secondary to aspiration event in the setting of altered
mental status. OSH ABG demonstrated elevated A-a gradient,
which could be suggestive of PE but CTA was negative for
pulmonary embolus. EKG with no acute ST changes. The patient
was treated with vancomycin and ceftriaxone for possible
meningitis. He was intubated and sedated on [**5-16**].
.
# FEVERS: The patient was febrile at OSH. Work-up there
included negative CT chest, CT head, TTE, and blood cultures.
He was started on meningitis coverage with
vancomycin/ceftriaxone/gentamycin. TEE showed valve vegetation
and open PFO. Gentamicin was added to his antibiotics to cover
culture-negative endocarditis. His WBC on transfer to [**Hospital1 18**] was
22.0, peaked at 42.9 on [**5-20**]. Patient continued to spike
without obvious source. However, he has been afebrile for the
last weeks. He continues on vancomycin and gentamycin through
[**2113-6-28**] for culture negative endocarditis. Patient will need a
repeat ECHO to evaluate for endocarditis on [**2113-6-28**].
.
# ALTERED MENTAL STATUS: Initially concerning for infectious
etiology (meningitis, endocarditis). On [**5-16**] patient was noted
to have both ischemic and hemorrhagic stroke, responsible for
his worsening mental status. His mental status however,
continues to improve. On discharge, he will open his eyes to
voice and respond to simply commands. According to neurosurgery
attending, patient will likely have residual hemiparesis,
diplopia, and difficulty with feeding.
.
# LEFT SUBCLAVIAN DVT: Patient will continue on heparin gtt
bridge to coumadin for mechanical valve and will thus be
anticoagulated for subclavian DVT as well.
.
# HEPATITIC C: Chronic. Not treated.
.
# CAD: Patient continues on metoprolol and statin. After
heparin drip is discontinued, it may be reasonable to start ASA
81mg QD. This can be discussed with neurosurgery and patient's
cardiologist/PCP.
.
# DEPRESSION/ANXIETY: Abilify and celexa were stopped during
admission due to critical illness and change in mental status.
These can be resumed at the discretion of outpatient providers.
.
# ANEMIA: Patient with combination of iron deficiency anemia
and anemia of chronic disease. He received 1 unit of PRBCs on
[**2113-6-20**] with appropriate bump in hematocrit. He should continue
on iron supplementation with frequent hematocrit checks.
.
# ANTICOAGULATION: Patient continues on coumadin with heparin
bridge. Patient's goal INR is 2.5-3.5 because of mechanical
mitral valve. His coumadin may need to be uptitrated upon
discharge.
.
# NUTRITION: Patient continues on isosource tube feeds through
PEG tube.
.
# GOALS OF CARE: Long discussions were held with family about
goals of care. As of now, patient is full code. Patient's
18-year-old daughter is the HCP but brother [**Name (NI) **] is responsible
for much of the coordination of care. Palliative care was
consulted during this admission; below is an exerpt: "I spoke
with [**Doctor Last Name **] on the phone, who seems to have a fairly balanced
perspective on the [**Hospital **] medical condition and prognosis. He
describes that as a family they are "hoping for the best" while
also "prepared for the worst" if things do not turn out well.
They are definitely hoping for as much neurologic and cognitive
recovery as possible. His medical team does expect him to have
some degree of improvement, the extent of which is less clear.
His brother describes that they want as much aggressiverehab as
possible. He states that he knows it is possible that the pt
may suffer some medical complications down the road and that if
he experiences anything quite devastating like another stroke,
he thinks that as a family they would opt for comfort-focused
care at that point to minimize the pt's further suffering. He
knows
that even prior to that point, there are options for avoiding
invasive or uncomfortable procedures, such as DNR/DNI. Overall
appears that pt's brother has realistic expectations and hopes
for the pt's future course, and is able to acknowledge that
quality of life is important for guiding future decisions if the
pt suffers any future major medical complications. Per the
brother's and RN staff recommendations, we have not pursued
further conversation with his daughter at this time due to her
young age, her social situation (18 yo, graduating from high
school this week, lost her mother 2 years ago and then
step-father last year) and the nonurgent nature of our topic of
conversation."
.
Transitional Issues:
--Repeat ECHO on [**2113-6-28**] to evaluate for continued endocarditis
--Ensure INR is between 2.5-3.5 and overlap with heparin gtt for
48 hours
--Daily creatinine checks while patient is on gentamycin
--Vanc IV and gent through [**2113-6-28**] for culture negative
endocarditis
--PEG care
--Check IV vanc and gent trough on [**2113-6-26**]
--Twice weekly hematocrit checks
--Tube feeds as recommended by nutrition
--Neurosurgery follow-up
--Consider starting ASA for CAD after patient is off heparin gtt
and OK with neurosurgery
--Continued goals of care discussion with family and palliative
care team
--Taper fludricortisone as above
.
If any questions, please call floor [**Hospital Ward Name 121**] 7 at [**Hospital1 18**] and ask for
the team that was taking care of this patient. Thanks!
Medications on Admission:
Home:
1. Gabapentin 300mg TID
2. Metoprolol 25mg [**Hospital1 **]
3. Magnesium oxide 400mg PO daily
4. Abilify 5mg PO qHS
5. Celexa 20mg PO daily
6. Coumadin daily
On transfer from outside hospital:
1. Tylenol 1000mg q6hr prn
2. Fioricet 1-2 tabs PO q4hr prn pain
3. Aripiprazole 5mg PO qHS
4. Suboxone 2/0.5- SL [**Hospital1 **]
5. Ceftriaxone 2gm q12hr
6. Celexa 20mg PO qHS
7. Gabapentin 300mg PO TID
8. Gentamicin 100mg q8hr
9. Nicotine 21mg TD daily
10. Senna 1 tab daily prn
11. Vancomyin 1500mg IV q12hr
12. Coumadin 15mg daily (on hold)
13. Heparin gtt (on hold)
14. Guaifenesin 200mg q6hr prn
15. Lorazepam 0.5mg PO q4hr prn anxiety
16. Magnesium oxide 400mg PO daily
17. Melatonin 1mg qHS
18. Metoprolol 25mg PO BID
19. Milk of Magnesium- 30ml PO daily
20. Propofol 40mcg/kg/min IV drip
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H
2. Ferrous Sulfate 325 mg PO DAILY
3. Fludrocortisone Acetate 0.1 mg PO BID
4. Gentamicin 80 mg IV Q12H
Last day [**2113-6-28**].
5. Heparin IV Sliding Scale
6. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
7. LeVETiracetam 1000 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
Hold for SBP <110; HR <60
9. Pantoprazole 40 mg PO Q12H
10. Simvastatin 20 mg PO DAILY CAD
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. Vancomycin 750 mg IV Q 12H, last day [**2113-6-28**]
13. Vancomycin Oral Liquid 500 mg PO Q6H
Please take through [**2113-6-28**].
14. Warfarin 7.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Endocarditis
Pneumonia
Respiratory failure
Stroke
Vasospasm
Intraventricular hemorrhage
Hydrocephalus
Coma
Protien/calorie malnutrition
C. diff colitis
Fever of unknown origin
malnutrition
Anemia
Leukocytosis
Thrombocytosis
Hyponatremia
endocarditis
Left subclavian DVT
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 75777**]
hypotension
altered mental status
Vasospasm
bactermia
Cerebral salt wasting
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 75772**],
It was a pleasure taking care of you during this admission. You
originally came to the hospital because you had an ischemic
stroke. You subsequently had a bleed in your head and you
needed a drain placed by neurosurgery to relieve the pressure.
We were unable to take you off the breathing machine
(respirator) and a tracheostomy was placed. You also had a PEG
tube placed so that you could get tube feeds and medications.
You have had multiple CT scans of your head; the most recent one
did not show much difference from the one before.
.
You will need to follow-up with neurosurgery (Dr. [**First Name (STitle) **] in [**2-24**]
weeks for a CT scan and an appointment.
.
You are on a heparin drip bridging you to therapeutic coumadin
levels. Your goal INR is 2.5-3.5 because of your mechanical
valve. You will need to continue on a heparin drip until your
INR is over 2.5 for 48 hours. You will need to have your PTT
checked (level of heparin) every 6 hours and adjusted so that it
is between 60 and 80.
.
You will be discharged on keppra for seizure prophylaxis.
.
You were given a blood transfusion on [**2113-6-20**] for low blood
counts probably because of iron deficiency anemia and anemia of
chronic disease.
.
You were started on a medication called fludricortisone to treat
low sodium levels. You will need to taper this medication very
slowly. On [**2113-6-22**], please taper fludrocortisone dose down to
0.1 [**Hospital1 **] for 3 days through [**2113-6-24**]. Then start 0.1QD for 3 days
through [**2113-6-27**]. Then start 0.05mg QD for 3 days through [**2113-6-30**].
Then stop.
.
You will continue on vanc IV 750 mg Q12 and gentamycin 80 Q12
for endocarditis through [**2113-6-28**]. You will need to have
creatinine checked every day. Gentamycin trough should be
checked on [**2113-6-26**] and adjusted accordingly (should be less than
2). Gentamycin is being dosed at 5am and 5pm. If creatinine
rises, gentamycin will need to be adjusted. Please check
vancomycin trough on [**2113-6-26**]. Vancomycin has been dosed at 10am
and 10pm.
.
We will continue to treat you for c.diff (infection of the
colon) with oral vancomycin through [**2113-6-28**] when you stop your
other antibiotics.
.
Please see below for a list of your new medications.
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2113-7-6**] at 2:15 PM
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: THURSDAY [**2113-7-6**] at 3:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 431, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4631
} | Medical Text: Admission Date: [**2130-9-3**] Discharge Date: [**2130-9-11**]
Date of Birth: [**2051-12-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo F w/ hx of depression, with worsening sx. not eating, not
walking. in bed most of day xweeks. She reports that this bout
of depression began 3-4 years ago. Could not specify a specific
trigger. "Its hard not to be depressed." + deconditioning.
Passive SI, no active HI. In the ED her VS on presentation were:
98.4, 84, 198/83, 98% on RA. Her blood pressure then rose to
224/63 in the ED. She received lopressor 5 mg IV x2, 10 mg IV x
1, 1 mg ativan, 10 mg hydralazine IV and 400 mg IV cipro. FS =
141 on presentation. She was also given 1L NS
Past Medical History:
Chronic depression- Long hx of depression, with her first
hospitalization when she was around 25 yo. The patient has had
[**1-1**] hospitalizations after that (unsure exactly how many). She
denied any suicide attempts in the past. She currently has a
psychiatrist Dr. [**Last Name (STitle) 48416**] ([**Telephone/Fax (1) 48417**]. No therapist.The
patient has had ECT treatments for her depression in the past
that had been successfull
DM
HTN
Likely CAD
Vitamin B12 def-dx this admission
Anemia
Social History:
Pt born and raised in [**State 350**]. She describes childhood as
good. She attended school until the 10th grade and worked as a
[**Last Name (un) 19441**] after that. She never married and has no children. She
is currently living in a house with her sister (who is also
demented per Dr. [**Last Name (STitle) 48416**] and her nephew. She collects SSI.
ADLS: Independent of ADLS when not depressed.
Family History:
Father with depression.
Physical Exam:
on discharge
Vitals: 98.5 132/60 84 18 99%RA
Access: PIV
Gen: nad, thin female lying in bed
HEENT: mm dry, missing teeth
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Chest: ecchymosis over right anterior chest and breast, mild
tenderness over swelling of soft tissue
Abd; soft, nontender, +BS
Ext; no edema
psych: flat affect
Pertinent Results:
chem panel unremarkable
Hgb 12--->10s
CK 1083-->400s
LFTs stable, albumin 3.3
Trop 2.71-2.91, finally drop to 2.26 [**9-8**], stop checking
TSH 0.76
Vit B12 146 (low), folate nl, ferritin 294
UA [**9-3**]: 21-50 wbc, mod LE, few bacteria
urine cx: contamination and >100K corneybacterium
blood cx [**9-3**] ntd X2
Imaging/results:
Xray L spine: osteopenia, no fracture
Echo normal EF >55%, mod TR and mod pulm HTN, otw normla
LE dopplers: no DVT b/l LE
CT head [**9-3**]: no acute intracranial process
CT chest [**9-8**]: Large right pectoral hematoma running along the
right breast into the anterior right axillary region, with a
large amount of subcutaneous soft tissue swelling. Mixed high
density is consistent with acute hemorrhage. No other hematoma
or fracture is seen.
A subpleural nodule in the left lower lobe measures 4 x 2 mm.
3-mm and 2-mm left upper lobe nodules are also noted.
Brief Hospital Course:
Pt was admitted from home on [**9-3**] per her nephew for essentially
failure to thrive and placement. Per the nephew, [**Name (NI) **], who is
her HCP, she has progressively been more depressed and less
attentive to her personal care. She has not been participating
in any activities, even ADLs. Around the time of admission, she
was so weak, he couldnt event get her off the toilet. He is also
caring for his ailing mother and it is very hard for him.
Upon admission, her CKs were mildly elevated to 1000s, thought
to be rhabdo [**12-31**] inmobility. She was hydrated and CKs
downtrended. However, her troponin was also checked on admission
given her BP was 242/60s and came back at 2.71. Repeat troponins
over the next 36hours oscillated between 2.71-2.93 as did CKMB.
Her EKG was unremarkable and she did not have any cardiac
complaints and was hemodyamically stable. Her Echo did not show
any WMA and EF was normal (only showed mod TR/pulm HTN) and LE
dopplers negative/good O2 sats. The etiology of her trop leak is
not very clear at this point, esp since it remains elevated when
her BP has improved (normal creat). Cardiology has also been
following and don't have a good explanation, ?tail end of
cardiac event a few weeks ago? vs hypertensive heart disease vs
less likely myocarditis. Given her RF for likely CAD, she was
started her on [**Last Name (LF) 4532**], [**First Name3 (LF) **] 325 and kept on the ACE/BB/statin.
Since there is no acute event and she is poor candidate for
cath/stent placement given ?compliance with [**First Name3 (LF) 4532**] if she needs
it, and pt not interested in pursuing cath, plan is to medically
manage and f/u with STRESS ECHO in on month (PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
was notified of this plan).
On [**9-8**], her hematocrit was noted to have dropped 10 points
throughout the day, and she had swelling and ecchymosis of the
right anterior chest. A CT scan showed a large right pectoralis
major hematoma. A code blue was called that evening because the
patient was noted to be unreponsive, not answering questions but
did respond to painful stimuli. SBP was int he 80s and
increased to 108 with a 500cc NS bolus. By the time of transfer
to the ICU, her mental status had already improved dramatically.
She received 2U PRBC that had been ordered earlier, and since
then her hematocrit has been stable at 27-29. Surgery was
consulted but felt that given the nature of the hematoma surgery
could potentially make it worse and recommended compression
dressings and limiting movement of the right arm. Etiology was
unclear but could have been minor trauma such as boosting in bed
or steadying her under the arm while ambulating in the setting
of recently-started anticoagulation with [**Month/Year (2) **] and [**Month/Year (2) **]. [**Month/Year (2) **] and
[**Month/Year (2) **] were stopped, cardiology was notified and agreed.
Her other issues include her c/o some prox LE
weakness/discomfort with ambulation. L spine films negative, no
objective weakness, ESR 14, CK down to 500s, TSH wnl. She was
participating in PT and her history was inconsistent, so this
was not w/u further at this time. She is also B12 def and she
was started on high dose oral supp (2000mcg qd) as well as other
vitamins per psych. Lung nodules were noted in the left lower
and upper lobes; as there was no CT available for comparison and
there is no history of smoking or malignancy, 1-year followup CT
is recommended
Medications on Admission:
Risperdal 1 mg qhs
Atorvastatin 10 mg qd
Calcium + D 1250/200
[**Month/Year (2) **] 81 mg
Lisinopril 5 mg qd
Vitamin D 400 IU qd
Glipizide 10 mg qd
Metformin 500 mg qd
Toprol 200 mg qd
Effexor 150 mg qd
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2561**] - [**Hospital1 8**]
Discharge Diagnosis:
Severe Depression
Elevated Troponin of unclear etiology (recent cardiac event vs
hypertensive heart disease and HTN urgency)
Rhabdomyolysis-mild
Vitamin B12 deficiency
Anemia
right pectoralis major hematoma
Discharge Condition:
Improved
Discharge Instructions:
You were admitted because you were having hard time taking care
of yourself and your nephew, [**Name (NI) **], was concerned for your
health.
You have severe depression that is not well controlled and you
will go to a facility to manage this.
While here you were found to have Vit B12 def and you were
started on Vitamin B12 supplemenation as well as other vitamins.
Also, your heart enzymes were elevated, the reasons for which
was not clear to us. Cardiology saw you while here and
recommended you get an outpatient Stress Echo.
You also had a bleed into the tissues of your right chest wall
after being placed on anticoagulation. Your [**Name (NI) **] and [**Name (NI) **] was
stopped and compression dressings applied per recommendation by
surgery, and after transfusion of 2 units of blood you remained
stable.
You will be followed by the doctors at your facility; if you
have lightheadedness, episodes of loss of consciousness,
evidence of active bleeding, fevers, chills, or any other
concerning symptoms, you may need to be transferred to another
facility for further medical care.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 month to set up
Stress echo. Call his office at [**Telephone/Fax (1) 1579**] to make an
appointment.
Please follow up with psychiatry as instructed by your
physicians after discharge from [**Hospital3 **].
ICD9 Codes: 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4632
} | Medical Text: Admission Date: [**2124-3-1**] Discharge Date: [**2124-3-10**]
Date of Birth: [**2124-3-1**] Sex: F
Service: Neonatology
HISTORY: Infant born at 32 4/7 weeks to a 43 year-old
gravida IV, para II mother with [**Name2 (NI) **] type O positive,
antibody negative, hepatitis B surface antigen, RPR
nonreactive, and rubella immune. Estimated date of
confinement [**2124-4-22**]. Prenatal course significant for the
following:
1. Mono/dichorionic twins with normal amniocentesis: 46XX x 2
2. Gestational diabetes, diet controlled.
3. Mother presented to [**Name (NI) **] Hospital on [**2-25**] with
preterm labor. She was noted to have increased uric acid and
low platelet count with normal [**Month (only) **] pressures. Magnesium was
started. Mother developed shortness of breath the following
day due to pulmonary edema and this resolved after magnesium
was discontinued. Mother was transferred to [**Hospital1 20311**] on [**2124-2-27**] for further care.
4. Mother received betamethasone and was complete on [**2-27**]
in the morning.
Infant delivered by cesarean section on [**2124-3-1**] at
12:20 due to concern for maternal pregnancy-induced
hypertension in the setting of abnormal laboratories. Infant
emerged legs first with good activity and good respiratory
effort and central cyanosis. Infant received blow-by oxygen
and was transferred to the Neonatal Intensive Care Unit with
mild to moderate respiratory distress. Apgar score at one
minute of 7 and at five minutes of 8.
INITIAL PHYSICAL EXAMINATION: Respiratory rate 50s,
temperature of 97.9, oxygen saturation on room air 91%.
Weight is 2130 grams (75th to 90th percentile), length of 44
cm (50th to 75th percentile), head circumference 32 cm (75th
to 90th percentile). Infant active and with anterior
fontanelle open and flat, palate intact, normal S1, S2, no
murmur, moderate respiratory distress, moderate
intercostal/subcostal retractions, breath sounds coarse,
bilaterally equal. Abdomen soft, nontender, nondistended.
Extremities well perfused, tone appropriate for gestational
age. Anus patent. Hips stable. Spine intact. No bruising or
rash noted.
HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Due to infant's
initial respiratory distress she was placed on CPAP of 6
between 24 and 30 percent. On day of life #2 infant was noted
to have increased work of breathing and intubated with pressures
of 21/5 and a rate of 20, room air to 30%. The infant did receive
two doses of surfactant and quickly weaned back down to CPAP of 6
on day of life #3. The infant was weaned off the CPAP to nasal
cannula on day of life #5 and has been in and out of low dose
nasal cannula since that time. Current dose of nasal cannula is
25 cc, 100% flow. Infant has had intermittent spells that are
mild. The greatest number of spells was on day of life #6, four
spells in 24 hours. There have been no bradycardic events in the
past 48 hours but the infant does have some evidence of periodic
breathing with mild desaturations. No caffeine has been
initiated.
CARDIOVASCULAR: The infant's [**Year (4 digits) **] pressures have remained
stable throughout the course. No murmur has been appreciated.
FLUIDS: Infant was started on feeds on day of life #3 and
fully advanced to full feeds by day of life #6. Infant is
currently on total fluids of 150 cc per kilogram per day of
24 calorie breast milk and Special Care. Feeds are gavaged over
one hour due to spits. The calories were adjusted to 20 to 24 on
[**2124-3-9**]. The infant's weight will need to be monitored to
determine whether more calories will be needed for adequate
growth. Initially the infant had normal glucose sticks that have
remained normal. A recent set of electrolytes on day of life #3
had a sodium of 145, potassium 4.9, chloride 111 and a
bicarbonate of 24. Current weight on [**3-9**] is [**2068**] grams, up
25 from the day before.
GASTROINTESTINAL: The infant had a peak bilirubin of 10.9 on
day of life #4, received single phototherapy and this was
discontinued on [**2124-3-8**] with a rebound bilirubin on [**2124-3-9**] of
3.3 up from 2.9 the day before.
HEMATOLOGY: Infant had a hematocrit of 43.9% and a platelet count
of 223K at birth.
INFECTIOUS DISEASE: The infant did receive a 48 hour course
of ampicillin and gentamicin due to possible concern for
infection (mother was group B strep positive and infant was born
premature). The CBC was notable for a white count of 10.9,
16 polys, 0 bands and 67 lymphs. [**Date Range **] cultures remained
negative at 48 hours and ampicillin and gentamicin were
discontinued at that time.
NEUROLOGY: There have been no neurological issues during this
time.
SENSORY: Infant will require a hearing screen prior to
discharge home. Of note, father does have a hearing loss.
OPHTHALMOLOGY: No examination has been done.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To level 2, [**Hospital **] Hospital. Name of
primary pediatrician unknown at this time.
CARE AND RECOMMENDATIONS: A. Feeds at discharge: Breast milk
24 calories per ounce, total fluids of 150 cc per kilogram
per day.
B. Medications: None.
C. Car seat screen not done.
D. State Newborn Screening status: Results pending.
E. Immunizations received: None.
F. Immunization 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 live immunization against influenza is
recommended for household contacts and out of home
caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity, twin
2. Hyaline membrane disease.
3. Apnea and bradycardia of prematurity, mild.
4. Indirect hyperbilirubinemia, resolved.
5. Rule out sepsis, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern4) 57175**]
MEDQUIST36
D: [**2124-3-9**] 11:01:27
T: [**2124-3-9**] 11:53:17
Job#: [**Job Number 60544**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4633
} | Medical Text: Admission Date: [**2154-3-3**] Discharge Date: [**2154-3-8**]
Date of Birth: [**2112-11-25**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Peppermint
Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
Anemia. Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 99778**] is a 41 year old female a history of warm
autoantibody hemolytic anemia diagnosed in [**2150**] who recently
underwent laparoscopic splenectomy on [**2154-2-20**] for disease
refractory to steroids, and refractory to rituximab and
cyclosporin. She tolerated the procedure well but has been
fatigued but has been experiencing abdominal pain since surgery
which is poorly controlled with Percocet. She has also felt
fatigued and dyspneic, consistent with prior episodes of
hemolysis. Because of her abdominal pain and fatigue she has not
been eating well and has not taken her cyclosporin for
approximately 2 days.
She initially presented with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital with
abdominal pain. She was found to have a WBC count of 30 and a
hematocrit of 10. On [**2154-2-26**] her WBC count was 13.4 with a
hematoctit of 25.1. She underwent a CT scan of the abdomen which
showed no evidence of acute bleeding or other etiology of her
abdominal pain. She received 4 units of non-crossmatched PRBCs
and solumedrol 125 mg IV x 1. She was transferred to [**Hospital1 18**] for
further management.
On arrival to the emergency room her initial vitals were T: 98.1
BP: 118/55 HR: 97 RR: 21 O2: 99% RA. She was evaluated by the
surgical service who reviewed the OSH CT scan and did not feel
that there was a surgical cause of her pain. She received 6 mg
IV Dilaudid for pain and 4 mg IV zofran.
On review of systems she endorses chills at home but did not
take her temperature. She denies chest pain or pressure. She
endorses dyspnea with exertion, lightheadedness, and fatigue.
She endorses diffuse severe abdominal pain with nauesa, no
vomiting. She has had diarrhea x 1 day but cannot describe
stools. She denies melena or hematochezia. She endorse decreased
urine output and dark urine. She has worsening jaundice. She has
no lower extremity edema or swelling. All other review of
systems negative in detail.
Past Medical History:
1. Idiopathic autoimmune hemolytic anemia: Diagnosed in [**3-4**]
admitted to the ICU with Hct 9.6, given high dose steroids and 6
units pRBC, developed steroid psychosis and tapered off. Refused
splenectomy then received 4 cycles Rituximab and has been on
cyclosporin since [**9-/2152**] and finally unwent splenectomy on
[**2154-2-20**].
2. Anxiety disorder: on benzodiazepines
3. Psoriasis with psoriatic arthritis
4. Crohn's disease, history of leukocytoclastic vasculitis by
biopsy in [**Month (only) 359**] Per pt this is inactive.
5. Basal Cell Carcinoma of Leg
6. Osgood-Schlatter (osteochondritis of the tibial tuberosity)
Social History:
Occasional ETOH use, no tobacco or illicit drug use.
Family History:
Mother with hemolytic anemia at 6 mth of age, uncle with
hemolytic anemia in infancy causing his demise. No family h/o
SLE or Crohn's. Brother has new onset atrial fibrillation.
Physical Exam:
On admission:
Vitals: T: 99.7 HR: 85 BP: 102/63 RR: 20 O2: 99% on RA
General: Tan, jaundiced, tearful and easily aggitated
Skin: Tanned skin, mild jaundice, no petechiae or rashes
HEENT: PERRL, EOMI, sclera icteric, MM moist, oropharynx clear
Cardiac: Regular rate and rhythm, normal s1 and s2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezez, rales,
ronchi
Abdomen: Soft, non-distended, +BS, well healing LUQ laparoscopic
sites, + voluntary guarding, no rebound
Extremities: Warm and well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: Alert and oriented x 3, strength 5/5 in upper and lower
extremities, sensation intact to light touch
=======================================
At time of discharge:
BP=160s-170s/80s-90s, HR=50-60
Abdomen: non-distended, soft, tolerating deep palpation with
minimal discomfort, normal bowel sounds.
Remainder of physical exam unchanged
Pertinent Results:
Labs on admission:
[**2154-3-3**] 04:30AM BLOOD WBC-28.0*# RBC-1.73*# Hgb-5.3*#
Hct-15.8*# MCV-91# MCH-30.9 MCHC-33.8 RDW-19.5* Plt Ct-1481*#
[**2154-3-3**] 04:30AM BLOOD Neuts-84* Bands-1 Lymphs-8* Monos-5 Eos-0
Baso-1 Atyps-0 Metas-1* Myelos-0 NRBC-5*
[**2154-3-3**] 04:30AM BLOOD PT-17.2* PTT-28.6 INR(PT)-1.6*
[**2154-3-3**] 04:30AM BLOOD Ret Man-11.2*
[**2154-3-3**] 04:30AM BLOOD Glucose-193* UreaN-39* Creat-1.3* Na-135
K-5.5* Cl-105 HCO3-17* AnGap-19
[**2154-3-3**] 04:30AM BLOOD ALT-33 AST-57* LD(LDH)-472* AlkPhos-254*
TotBili-2.8* DirBili-1.4* IndBili-1.4
[**2154-3-3**] 04:30AM BLOOD Lipase-22
[**2154-3-3**] 04:30AM BLOOD UricAcd-8.3*
[**2154-3-3**] 04:30AM BLOOD Hapto-261*
[**2154-3-4**] 04:00AM BLOOD Cyclspr-128
CT abdomen/pelvis [**2154-3-3**]:
1. Heterogeneous perfusion of the liver related to thrombosis of
the right portal vein, main portal vein, splenic vein, and SMV.
Note is made of thrombus extending into extensive
retroperitoneal collaterals.
2. Abnormal bowel wall thickening involving the sigmoid colon,
which may
relate to venous congestion.
3. Patent hepatic veins, in arterial system. No IVC thrombosis.
4. Gas in the soft tissues of the left anterior abdominal wall.
Recommend clinical correlation with recent surgery.
CXR:
Bilateral pleural effusions, right greater than left, are new,
are associated with adjacent atelectasis. The upper lungs are
clear. Moderate cardiomegaly is unchanged.
Discharge Labs:
[**2154-3-8**] 07:15AM BLOOD WBC-17.5* RBC-3.88* Hgb-11.9* Hct-36.6
MCV-94 MCH-30.8 MCHC-32.6 RDW-18.8* Plt Ct-985*
[**2154-3-8**] 07:15AM BLOOD PT-20.7* PTT-96.7* INR(PT)-1.9*
[**2154-3-8**] 07:15AM BLOOD Glucose-140* UreaN-21* Creat-1.0 Na-144
K-4.6 Cl-104 HCO3-27 AnGap-18
[**2154-3-8**] 07:15AM BLOOD LD(LDH)-346*
[**2154-3-5**] 03:45AM BLOOD Mg-2.1
[**2154-3-3**] 04:30AM BLOOD Hapto-261*
[**2154-3-3**] 08:17PM BLOOD Hapto-239*
[**2154-3-4**] 04:00AM BLOOD Hapto-243*
[**2154-3-5**] 03:45AM BLOOD Hapto-233*
Brief Hospital Course:
Ms. [**Known lastname 99778**] is a 41 year old female with warm autoimmune
hemolytic anemia who presented ten days status-post splenectomy
with abdominal pain and dyspnea with a hematocrit of 11 and some
evidence of hemolysis.
Anemia: Her laboratories at OSH were consistent with but not
diagnostic of hemolysis; she did not display signs of active
bleeding. The haptoglobin at [**Hospital1 18**] was elevated pointing against
hemolysis. Given her low hematocrit. She was initially managed
in the ICU. A CT scan at [**Hospital1 18**] showed extensive clot burden in
her portal system, likely related to her prior surgery. She
received four units of major antibody crossmatched blood, and
additional tubes were sent to the Red Cross for further
crossmatching.
Hematology saw the patient in the emergency room, and
recommended treatment with steroids and cyclosporine. She was
started on Solumedrol 80mg IV daily and Cyclosporine 150mg PO
q12hours. Hemolysis labs were monitored as well as Cyclosporine
levels. The Surgical team also followed the patient in the ICU.
After transfer to the medical floor, Hct gradually rose daily to
36.6 at time of discharge. Solumedrol was tapered and converted
to prednisione. Cyclosporine was also tapered to 75mg [**Hospital1 **]. LDH
was persistently elevated likely secondary to abdominal clot
process. F/u was scheduled with her hemtologist, Dr. [**Last Name (STitle) 2148**].
Abdominal Pain/Portal thrombus: The pain was diffuse, severe,
and out of proportion to exam. CT scan of abdomen did show large
portal clot burden. Empiric metronidazole was started until a
C.diff could be obtained, but as pt did not have a BM, it was
continued until day of discharge. Her pain was controlled with
Dilaudid as needed. Her diet was advanced to regular, but on
the day of discharge (against medical advice), she did not
tolerate jello without IV dilaudid. Plan was for pt to remain
until able to tolerate clears with only po pain meds, but she
chose to leave AMA (form signed). She has f/u scheduled with Dr.
[**Last Name (STitle) **] within one week. Expressed understanding of need to
return if abdominal pain increases. Given 5 days worth of home
dose of percocet.
Thrombocytosis: Likely related to recent splenectomy, improved
from 1.5 million to 900K at time of d/c.
Leukocytosis: Likely reactive process + related to high dose
steroids. No fevers. No localizing sources of infection with
the exception of abdominal pain. She was started on empiric
Flagyl which was discontinued at time of discharge. White count
peaked at 36 and fell to 17.5 at time of discharge.
Acute Kidney Injury: Creatinine 1.3 from baseline < 1.0. The
was felt to most likely be prerenal from dehydration. This
returned to baseline prior to d/c.
.
Hypertension: likely secondary to steroids and cyclosporine. not
stating anti-htn at this time, continue to monitor; should
improve with taper. BPs peaking in the 170/80 range at time of
discharge.
.
Anxiety: The patient was noted to be very anxious, and this
seemed to worsen after the initiation of steroids. There is
concern that the steroid is causing side effects, including
psychosis, as it had done in the past according to the patient.
She was continued on home benzodiazepines (Klonopin), as well as
Haldol PRN. Disscharged on home klonopin dose.
***PT DISCHARGED AMA. Our recommendation was that she stay
until being able to tolerate po with only percocet for pain
control. She signed AMA form and expressed understanding of
risks.
Medications on Admission:
Benzoyl Peroxide cleanser
Clobetasol cream
Clonazepam 1 mg [**Hospital1 **]:PRN
Cyclosporin 150 mg [**Hospital1 **]
Folic Acid 6 mg daily
Omeprazole 40 mg daily
Percocet 7.5-325 mg tablet 1-2 tabs Q6H:PRN
Paroxetine 30 mg daily
Calcium-Vitamin D
Magnesium [**Hospital1 **]
Multivitamin
Discharge Medications:
1. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day:
prophylaxis.
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
8. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Disp:*180 Capsule(s)* Refills:*0*
9. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Multivitamins Oral
13. Percocet 7.5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
autoimmune hemolytic anemia
portal vein thrombosis
thrombocytosis
anxiety
Discharge Condition:
Discharged against medical advice. Is not tolerating solid food
without IV dilaudid at the time of discharge.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] with severe abdominal pain and a very
low blood count. You received a blood transfusion at an outside
hospital and another one here. At the time of discharge, your
blood counts were nearing the normal range. A scan of your
abdomen showed a large amount of blood clots in the vessels that
drain your intestines. For this, you will need to be
anticoagulated for some time.
You are being discharged against medical advice. We strongly
advise you to stay until you were able to tolerate food without
IV pain medication. There is a risk that advancing your diet
without medical supervision may lead to an acute abdomen process
requiring urgent intervention.
Please return to the hospital if you develop: severe abdominal
pain, fevers, chills, sweats, dizziness, blood in your stool,
tarry stools, any other form of bleeding, severe headache,
chenage in vision, or any other symptom which seriously concerns
you.
Several changes were made to your medications:
- cyclosporin has been reduced to 75mg twice daily
- prednisone 30mg daily has been started
- warfarin 5mg daily has been started
- bactrim (single strength) has been started
- omeprazole, paroxeteine, clonazepam, calcium/vitamin D, and
folic acid have been continued at previous doses.
Followup Instructions:
We have scheduled you an appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **],
MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2154-3-14**] at 11:45am
Please call Dr.[**Name (NI) 7750**] office today and make an appointment
for Tuesday [**3-12**]. It is very important that you make this
appointment, you will need to have your INR (blood thinning)
checked.
Completed by:[**2154-3-8**]
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4634
} | Medical Text: Admission Date: [**2169-8-13**] Discharge Date: [**2169-8-21**]
Date of Birth: [**2113-12-18**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fever and abdominal pain
Major Surgical or Invasive Procedure:
Central venous line placement [**8-13**]
History of Present Illness:
Ms. [**Known lastname 26442**] is a 55 yo female with a history of chronic hepatitis
C infection (last HCV viral load 3190 copies on [**8-9**])
complicated by cirrhosis on weekly pegylated interferon therapy,
now presenting with a 1-day history of fever and 2-day history
of abdominal pain.
She was seen in the [**Hospital **] clinic on [**8-9**] for administration of
interferon, at which time a routine U/S was also performed which
was normal. She was doing well at that time. She first noted
some malaise and weakness on [**8-11**], along with new onset
abdominal pain, which has persisted. She describes constant RUQ
abdominal pain, approximately [**2174-4-18**], non-cramping, some
radiation to back/right flank, associated with some N/V. Emesis
X 3 one day PTA, non-bloody, no coffee grounds. She also reports
a 2-day history of watery BM, about [**2-16**] BMs per day, small
volume, ? some mucous. No relief of abominal pain with
defecation. Yesterday, she woke up with severe chills, did not
measure temperature. ROS otherwise remarkable for a 3-day
history of headache, no photophobia or phonophobia. No URI
symptoms, no GU symptoms. No recent abx, no recent travel, no
known sick contacts, no unusual food. Poor appetite, little PO
intake in past 3 days.
In ED, initial vitals T 104.9, BP 138/65, HR 118 regular, RR 22,
Sat 98% on room air. She was pancultured and given Levofloxacin
500 mg IV and Flagyl 500 mg IV and aggressively hydrated with NS
4L. Lactate 4.4, RUQ U/S negative for acute pathology.
Past Medical History:
1. Chronic hepatitis C infection on pegylated interferon therapy
since [**66**]/[**2169**]. Last HCV viral load 3190 copies on [**8-9**]. Last
AFP 11.1 on [**2169-6-21**]. Normal abdominal U/S on [**8-9**] without
ascites or focal hepatic lesion.
2. Cirrhosis [**2-15**] chronic hepatitis C infection
3. Status post TAH-BSO for fibroid uterus in [**2155**]
Social History:
She lives alone. SHe has one son who lives in [**Name (NI) 108**]. Active
smoker, about 3 packs/week X >20 years. No EtOH, no history of
IVDU. History of blood transfusion in [**2155**]. She works as a store
manager.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VITALS: Tm 104.9, Tc 101.6 after 650 mg of Tylenol, BP
99-130/40-70, Hr 100-115, Sat 98% on room air.
GEN: Lying flat, looks tired.
HEENT: Sclera anicteric. Slightly dry MM. Clear OP, without
lesions.
NECK: No nuchal rigidity. No cervical [**Doctor First Name **].
RESP: Chest CTAB. No adventitious sounds.
CVS: Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS NA. Abdomen non-distended. Hypogastric abdominal scar.
RUQ tenderness, without guarding or rebound. No mass palpable.
No [**Doctor Last Name **] sign. Mild right CVA tenderness. DRE performed --> no
stool in rectal vault. Guaiac negative, but limited sample. No
rectal mass.
EXT: Without edema. Warm, well-perfused. Strong pedal pulses.
NEURO: Alert and oriented X 3. Non-focal.
INTEG: No rash. No ulcer.
Pertinent Results:
LABS on admission:
CBC:
WBC 9.5, Hct 43.0, Plt 53 (down from 81 on [**8-9**]), MCV 90. Diff
with N 94.2, 4.2 Ly.
Chemistry:
Na 132, K 3.3, Cl 98, HCO3 21, BUN 16, Creat 0.9, Gluc 184.
ALT 94, AST 69, ALP 92, Amylase 52, Lipase 32, T bili 1.2
(direct 0.6 up from 0.2). LFTs stable versus [**8-9**].
Fibrinogen 592, D-dimer 3266
U/A: Clear, sg 1.018, Blood mod, Prot tr, gluc 100. Neg leuk,
neg nitrite. RBC 0-2, WBC [**6-23**], many bacteria.
Other Petinent Labs:
.
[**2169-8-13**] 09:38PM O2 SAT-78
[**2169-8-13**] 09:16PM HCT-34.7*
[**2169-8-13**] 09:00PM CORTISOL-37.2*
[**2169-8-13**] 08:03PM LACTATE-1.1
[**2169-8-13**] 07:37PM GLUCOSE-132* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-18* ANION GAP-10
CALCIUM-6.7* PHOSPHATE-2.4*# MAGNESIUM-1.4*
[**2169-8-13**] 07:37PM WBC-7.2 RBC-3.99* HGB-12.4 HCT-35.9* MCV-90
MCH-31.0 MCHC-34.4 RDW-13.7 NEUTS-90.4* BANDS-0 LYMPHS-7.5*
MONOS-2.0 EOS-0 BASOS-0.1 PLT SMR-VERY LOW PLT COUNT-44*
.
[**2169-8-13**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-NEG
BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-[**6-23**]*
BACTERIA-MANY YEAST-
NONE EPI-0-2 TRANS EPI-<1 MUCOUS-FEW
Urine grew E.coli
.
[**2169-8-13**] 12:15PM ALT(SGPT)-94* AST(SGOT)-69* ALK PHOS-92
AMYLASE-52 TOT BILI-1.2 DIR BILI-0.6* INDIR BIL-0.6 LIPASE-32
[**2169-8-13**] 12:15PM CRP-107.0*
[**2169-8-13**] 12:15PM PT-13.7* PTT-28.2 INR(PT)-1.2
[**2169-8-13**] 12:15PM FIBRINOGE-594* D-DIMER-3266*
*
MICRO:
[**8-13**] Blood cx X 2 Positive for E.coli, Urine Cx Positive for
E.coli
10,000-100,000; Pan-sensitive
[**8-14**] Blood Cx x 2: negative
[**8-14**] Stool Cx: negative for C. diff, Campylobacter
[**8-16**] IJ Catheter Tip culture: negative for growth
[**2169-8-17**]: Right Renal Abscess Drainage:
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S) =
Levofloxacin-sensitive E.coli.
[**8-17**] Urine cx: negative
[**8-/2169**] Blood Cx: negative
[**8-18**] Stool Cx: negative for C.diff
[**8-19**] Blood Cx: negative
[**8-19**] Urine Cx: negative
[**8-21**] Blood Cx: negative
.
IMAGING:
[**2169-8-13**] CXR: No acute cardiopulmonary process.
[**2169-8-13**] RUQ U/S (preliminary): Pericholecystic fluid, small
amount of sludge, no biliary ductal dilatation, no [**Doctor Last Name 515**], no
son[**Name (NI) 493**] evidence of cholecystitis
[**2169-8-17**] Abdominal CT: Semisolid, semi-cystic mass in the
superior pole of the right kidney measuring approximately 3.2 x
4.4 cm, and which is likely infectious in etiology given the
associated perinephric stranding and fascial thickening; Shotty
lymphadenopathy in the pre-pericardial as well as the
retroperitoneal areas; Bilateral pleural effusions, periportal
and pericholecystic fluid which could all be consistent with
slight volume overload. Successful aspiration of a right renal
lesion, which is suspected to be a renal abscess.
Brief Hospital Course:
55 year old female with history of HepC admitted with fever,
chills, abdominal pain found to have urosepsis with E.coli by
urine and blood cultures, and renal abscess seen by CT Scan was
drained and grew E.coli.
Hospital course was significant for the following issues:
1. Sepsis: The patient had high grade GNR bacteremia with
pan-sensitive E. coli from urinary source. She was entered in
the sepsis protocol and a R IJ central line was placed. Her
hypotension and lactic acidosis responded to aggressive fluid
resuscitation. She was treated with levofloxacin. She was also
initially treated with metronidazole given her diarrhea but this
was stopped as her diarrhea improved. Stool cultures were
negative for C. Diff, Campylobacter, Enteric GNR, Salmonella,
and Shigella. SIRS + evidence of lactic acidosis and
hypotension responded to IVF without addition of pressors.
RUQ US revealed no acute biliary process, no ascites. The
patient had a CT of the abdomen which revealed a bulging, but
wedge-shaped area of hypoattenuation within the upper pole of
the right kidney which likely represents a focal area of
pyonephrosis. Less likely, this may represent a renal mass and
follow- up is recommended after treatment. Urology was
consulted regarding whether there was a fluid collection/abscess
that required drainage. Ultimately the area was determined to
be an abscess and was drained by interventional radiology.
Aspirate from abscess on R kidney from [**8-17**] showed 3+ PMNs and 1+
GNR, which was determined to be E.coli without anaerobes,
susceptible to Levofloxacin, with which the patient was being
treated. Following drainage of the right renal abscess the
patient's temperature increased to 102 initially and was treated
with ibuprofen with good effect. She was also monitored for
blood in urine; inability to urinate; shaking, chills or fever;
back pain; or severe pain at biopsy site. The patient did not
develop any such complications due to the renal abscess drainage
during her hostpital course.
The patient's pain was controlled with oxycodone 5mg q4-6
hours, which the patient required 2 - 3 times per day. Her pain
at baseline and pain on palpation improved, allowing the patient
to ambulate normally on [**8-20**] and [**8-21**]. The patient will have a
follow-up CT in 4 weeks and will see urology for a follow-up
appointment after that.
2. Hepatitis C/cirrhosis: The patient's last HCV viral load
down to 3190 copies on pegylated interferon therapy. The patient
was followed by the hepatology service while in house. Her
interferon therapy was discontinued while in house. She will
follow up with her Hepatologist Dr. [**Last Name (STitle) 7033**] following discharge
for discussion regarding treatment of her Hepatitis C.
Hepatotoxic medications were avoided. The patient was counseled
to avoid Acetominophen. There were no acute issues related to
the patient' Hepatitis C during her hospital course and LFTs
were stable and within the normal range.
3. Thrombocytopenia: The patient's platelets count decreased
down to 53 upon admission, down from 81 on [**8-9**]. This was
suspected to be secondary to the patient's Hepatitis C with
cirrhosis and possibly due to the interferon therapy. DIC
work-up negative with fibrinogen >300, INR stable. The patient
had faint petechiae around her ankles on [**8-18**] and [**8-19**] which had
resolved by [**8-20**]. The patient had no other evidence of bleeding.
Her platelet count steadily rose during her hospital course,
and was 198 at discharge.
Medications on Admission:
1. Weekly pegylated interferon therapy, last dose on [**2169-8-9**]
2. Lexapro 10 mg PO QD (has been taking only intermittently)
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever.
3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
bacteremia with E.coli, likely urosepsis
urinary tract infection
right pyelonephrosis and kidney abscess
Discharge Condition:
stable, tolerating POs, ambulating
Discharge Instructions:
-contact MD if you develop fever/chills, abdominal pain,
worsening flank pain, or other concerning symptoms
-follow-up with Liver Clinic about when to restart your
interferon medication
Followup Instructions:
-follow-up with primary care physician [**Name Initial (PRE) 176**] 2-4 weeks
-Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2169-11-8**] 11:15
-you have a Cat Scan ordered for [**2169-9-18**] to relook at
your right kidney. Please call 617=[**Telephone/Fax (1) 57066**] within the next week
to schedule an exact appointment time.
-please call [**Hospital 159**] Clinic ([**Telephone/Fax (1) 164**]) for an appointment in
late [**Month (only) **] or Early [**Month (only) 359**] for follow-up on your kidney
infection.
Completed by:[**2169-8-22**]
ICD9 Codes: 5990, 2762, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4635
} | Medical Text: Admission Date: [**2197-1-1**] Discharge Date: [**2197-1-5**]
Date of Birth: [**2119-3-10**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
dysarthria and left sided weakness
Major Surgical or Invasive Procedure:
IVtPA, IAtPA, MERCI retrieval, intubation, extubation
History of Present Illness:
Please note, the patient's name is [**Name (NI) **] [**Known lastname 17976**], DOB [**2119-3-10**]
HPI: The patient is a 76 year old right handed man with a
history
of atrial fibrillation off Coumadin since [**12-23**] in the setting of
recent endoscopy, hyperlipidemia, and DM who presents with
dysarthria and left sided weakness who was called as a CODE
STROKE.
The patient was driving home from the Celtics game tonight with
his wife in the car. He was last seen normal at 5:50 pm. His
wife
noticed that while driving, started veering toward the island in
the left side of the road. He was able to stop the car. When his
wife evaluated him, he had dysarthria and left sided weakness.
They had stopped in front of a fire station, so EMS was
immediately on the scene. FSBG 152. They pulled him out of his
truck, and immediately took him to [**Hospital3 **].
This author heard the radio call in, so was immediately at the
patient's bedside at 6:14 pm. The CODE STROKE was officially
called at 6:21 pm. His NIHSS score was 17 (as listed below).
Head
CT showed no ICH but did show probable right insular loss of
[**Doctor Last Name 352**]-white differentiation compatible with right MCA infarct.
His
guaiac was negative. At 7:22 pm, the patient received IV tPA.
Approximately 45 minutes after the IV tPA he was getting tone
back in his left arm, and could lift his left leg off the bed.
CTA head/neck showed a thrombus in the right MCA, so the patient
was taken to intervention with 5 mg IA tPA and Merci retrieval,
with recanalization at the end of the procedure.
On ROS, the patient denied diplopia or dysphagia.
NIHSS Score:
1a. LOC: 0
1b. LOC Questions: 0
1c. Commands: 0
2. Best Gaze: 1 -right gaze preference but can just get past
midline to the left
3. Visual Fields: 2 -does not blink to threat on the left
4. Facial Palsy: 3 -both upper and lower facial weakness
5. Motor Arm: 4 -on the left
6. Motor Leg: 3 -flicker of contraction on the left leg
7. Limb Ataxia: 0
8. Sensory: 2 -unable to feel pinprick in the left arm and leg
9. Best Language: 0 -speech fluent
10. Dysarthria: 1 -moderate slurring
11. Extinction/Neglect: 1 -extinction to DSS (tactile) on the
left
NIHSS Score Total: 17
Past Medical History:
Atrial fibrillation on Coumadin (but off Coumadin since [**12-23**] for
endoscopy with biopsy)
Diabetes mellitus
Hypercholesterolemia
Barrett's esophagus
Proteinuria
s/p appendectomy
s/p right hip replacement
s/p colecystectomy
Social History:
He is a former pathologist at [**Hospital1 **]. He lives at
home with his wife. [**Name (NI) **] smoked occasionally in medical school,
but does not currently smoke. He
drank a scotch last night, but does not regularly drink EtOH. He
does not use illicit drugs.
Family History:
His father had a stroke, and his maternal uncle had DM.
Physical Exam:
VS: temp 98.4, bp 133/76, HR 75, RR 19, SaO2 98% on RA
Genl: Awake, alert
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to his name, age, and month. Follows commands
to
squeeze hand on the right and close eyes. Speech is fluent
without aphasia, able to name glove, chair, and key only on the
stroke scale card. He is able to relay history about the Celtics
game he just attended. Moderate dysarthria. Neglects the left
side.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Right gaze preference with decreased blink to
threat on the left. Can just get his eyes past midline to the
left. Flat left NLF, and cannot keep his left eyelid closed
against resistance. Tongue midline.
Motor: Decreased tone in his left arm, increased tone in his
bilateral LE. No observed myoclonus, asterixis, or tremor. He
can
keep his right arm above gravity x10 seconds, but cannot move
his
left arm at all. He can keep his right leg above gravity x5
seconds, but there is only a flicker of contraction of his left
leg.
Sensation: Decreased pinprick sensation in his left arm and leg,
normal on the right. Extinction to DSS (tactile) on the left.
Reflexes: 3+ and symmetric in biceps, brachioradialis, triceps,
and knees. 0 and symmetric in ankles. Toes upgoing bilaterally.
Coordination: Finger-nose-finger normal on the right.
Gait: Deferred
***Repeat neurological exam approximately 45 minutes after IV
tPA
showed improving tone in his left arm, and could lift his left
leg off the bed.
Examination at time of discharge:
Pertinent Results:
Labs on admission:
[**2197-1-1**] 06:20PM BLOOD WBC-9.1 RBC-4.63 Hgb-14.3 Hct-42.4 MCV-92
MCH-31.0 MCHC-33.8 RDW-13.4 Plt Ct-183
[**2197-1-1**] 06:20PM BLOOD PT-12.3 PTT-23.9 INR(PT)-1.0
[**2197-1-1**] 11:40PM BLOOD Glucose-132* UreaN-20 Creat-0.9 Na-135
K-4.1 Cl-103 HCO3-24 AnGap-12
[**2197-1-1**] 07:15PM BLOOD CK(CPK)-50
[**2197-1-2**] 03:47AM BLOOD CK(CPK)-104
[**2197-1-2**] 03:47AM BLOOD CK-MB-5 cTropnT-<0.01
[**2197-1-1**] 07:15PM BLOOD cTropnT-<0.01
[**2197-1-1**] 11:40PM BLOOD Calcium-8.5 Phos-2.5* Mg-1.8
[**2197-1-2**] 03:47AM BLOOD Digoxin-1.2
Urine studies:
[**2197-1-1**] 07:15PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2197-1-1**] 07:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2197-1-1**] 07:15PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0
Imaging Studies:
[**2197-1-1**]:
CT head:
1. No acute intracranial hemorrhage.
2. Hypodensity with loss of [**Doctor Last Name 352**]-white matter differentiation in
the right
posterior and inferior insular cortex may represent an acute
infarction. CTA with perfusion is pending
CTA head/neck, CTP:
IMPRESSION: Segmental occlusion of the M1 and M2 segments on the
right with increased mean transit time and decreased blood flow
with moderate decrease blood volume, punctate calcifications are
identified at the carotid bifurcations in the neck with soft
plaque on the right. No significant stenosis is identified.
[**1-2**] MRI w/o:
IMPRESSION: Limited examination, the axial FLAIR, and axial
diffusion-
weighted images demonstrate areas with acute/subacute ischemia,
involving the right basal ganglia and right temporal lobe. There
is no evidence of acute hemorrhagic transformation or mass
effect. Metal artifact is noted on the left, malar region.
Restricted diffusion and high-signal is noted on the DWI and
FLAIR
images, involving the right caudate nucleus, right lentiform
nucleus, and also the right external capsule, with extension at
the tip of the right temporal lobe.
[**1-2**] ECHO -
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild mitral
regurgitation with mildly thickened leaflets.
[**1-2**] CT head non contrast:
Again seen is a 7-mm metallic foreign body in the subcutaneous
tissues of the left malar eminence. Again demonstrated is marked
mucosal thickening of the bilateral maxillary and ethmoid
sinuses, with bilateral occlusion of the ostiomeatal units. The
mastoid air cells and remainder of the paranasal sinuses are
clear. There are no fractures.
Evolving right MCA infarct with no evidence of large acute
hemorrhage
CXR:
[**2197-1-5**] 06:05AM BLOOD Plt Ct-143*
[**2197-1-5**] 06:05AM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2*
[**2197-1-4**] 04:55AM BLOOD Plt Ct-171
[**2197-1-2**] 03:47AM BLOOD PT-12.9 PTT-24.8 INR(PT)-1.1
[**2197-1-5**] 06:05AM BLOOD WBC-7.2 RBC-3.78* Hgb-11.5* Hct-34.0*
MCV-90 MCH-30.5 MCHC-33.8 RDW-13.4 Plt Ct-143*
[**2197-1-4**] 04:55AM BLOOD WBC-8.4 RBC-4.01* Hgb-12.6* Hct-36.4*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.5 Plt Ct-171
[**2197-1-3**] 02:51AM BLOOD WBC-9.3 RBC-3.96* Hgb-12.1* Hct-36.2*
MCV-91 MCH-30.5 MCHC-33.4 RDW-13.4 Plt Ct-149*
[**2197-1-2**] 03:47AM BLOOD WBC-7.9 RBC-4.23* Hgb-13.0* Hct-38.7*
MCV-92 MCH-30.7 MCHC-33.6 RDW-13.7 Plt Ct-165
[**2197-1-1**] 11:40PM BLOOD WBC-9.4 RBC-4.18* Hgb-12.8* Hct-37.8*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.3 Plt Ct-169
[**2197-1-5**] 06:05AM BLOOD Glucose-144* UreaN-15 Creat-0.8 Na-138
K-3.8 Cl-105 HCO3-25 AnGap-12
[**2197-1-4**] 04:55AM BLOOD Glucose-160* UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2197-1-2**] 03:47AM BLOOD CK(CPK)-104
[**2197-1-1**] 07:15PM BLOOD CK(CPK)-50
[**2197-1-1**] 07:15PM BLOOD Lipase-29
[**2197-1-3**] 02:51AM BLOOD %HbA1c-6.3* eAG-134*
[**2197-1-2**] 03:47AM BLOOD Triglyc-235* HDL-30 CHOL/HD-3.6
LDLcalc-31
[**2197-1-2**] 03:47AM BLOOD Digoxin-1.2
[**2197-1-1**] 07:15PM BLOOD Digoxin-1.0
[**2197-1-1**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
76 year old RHM with atrial fibrillation (off Coumadin since
[**12-23**] in the setting of recent endoscopy), hyperlipidemia, and DM
who presented with dysarthria and left sided weakness, found to
have a R MCA cardioemboic stroke (initial NIHSS of 17: R gaze
preference, decreased blink to threat on the L, L face
paralysis, LUE plegia, and paresis of LLE with moderate
dysarthria, and extinction to DSS on the L).
CT revealed a right insular loss of [**Doctor Last Name 352**]-white differentiation,
CTA with an occlusion of R MCA. Patient received IV tPA, with
improved tone in left arm and strength of left leg. CTP showed
a MCA distribution MTT deficit w/ a much smaller blood volume
abnormality suggesting a sizeable penumbra, thus patient
underwent IA tPA and MERCI retrieval with recanalization.
NEURO. Stroke likely cardioembolic in the setting of atrial
fibrillation while not taking Coumadin. Exam improved to [**2-27**] LUE
AND LLE strength with left deltoid strength of [**12-30**], right gaze
preference and mild dysarthria at the time of discharge.
Repeat CT showed evolution of the R MCA infarction as noted on
prior imaging (see pertinent results) and no hemorrhage.
He was continued on Statin, metoprolol. TTE showed no thrombus,
LVEF 60%. Coumadin restarted on [**2197-1-2**] and he was bridged with
ASA 325mg daily. Once INR reaches [**12-28**] for 24 hours, ASA can be
discontinued. He is on coumadin 5 mg nightly.
CV. Atrial fibrillation, rate controlled. Continued on home
digoxin and llisinopril was restarted. Metoprolol was started
and then increased to home dose of 50mg in am and 25mg in pm.
He takes the XL form at home, but this can not be crushed so he
was discharged on another formulation. Home digoxin dose is at
half of his home dose at discharge. Digoxin level was normal.
PULM. Intubated for IA TPA and MERCI. Extubated on [**2197-1-2**]
without complications. On [**2197-1-4**], he developed crackles on lung
exam and CXR showed increased infiltrate on RLL and was started
on clindamycin for aspiration pneumonia. [**2197-1-4**] is day [**1-2**].
GI. Patient was maintained on PUD ppx. Due to somnolence, he
was unable to swallow safely. Dobhoff feeding tube was placed
for TFs as well as PO medication administration. This was later
replaced with NG tube on [**2197-1-4**]. He had failed two speech and
swallow evaluations most likely secondary to sleepiness. On
[**2197-1-4**], he was advanced to puree and thick nectar. He should be
supervised during administration of puree.
The patient was discharged to rehab.
Medications on Admission:
Coumadin 5 mg daily (he has been off this since [**12-23**] after
endoscopy with biopsy)
Metformin 1000 mg daily
Toprol XL 50 mg qAM, 25 mg qPM
Lisinopril 10 mg daily
Digoxin 0.25 mg daily
Simvastatin 40 mg daily
Omeprazole 40 mg daily
Fish Oil 3000 mg daily
Discharge Medications:
Coumadin 5 mg daily
Metformin 1000 mg daily
Toprol 50 mg qAM, 25 mg qPM
Lisinopril 10 mg daily
Digoxin 0.125 mg daily
Simvastatin 40 mg daily
Omeprazole 40 mg daily
Fish Oil 3000 mg daily
ASA 325 mg as a bridge to therapeutic INR on coumadin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary: Cardioembolic stroke (Right MCA M1-2 territory)
Secondary: Atrial fibrillation, hypertension, diabetes
Discharge Condition:
Neurological exam at time of discharge notable for: [**2-27**] LUE and
LLE strength, mild dysarthria, right gaze preference, left
neglect.
Neurological exam at time of discharge notable for:
Discharge Instructions:
You were admitted to [**Hospital1 18**] after having a stroke caused by a
clot in the blood vessel in your brain. You were found to have
significant L sided weakness and vision changes. Because of
this, you were treated with a medication to help dissolve the
clot (intravenous and intraarterial tPA) as well as underwent an
procedure to remove your clot (MERCI). With this treatment,
your weakness improved significantly.
You had the stroke due to a clot from your heart that was likely
caused due to having not taken your coumadin. Your coumadin has
now been restarted.
Your course was complicated by:
- Difficulty swallowing requiring feeding tube placement
- infiltrate on chest Xray and you are being treated with
antibiotics
The following changes were made to your medications:
- You were given lower doses of your blood pressure medications,
but they have now been restarted.
-You were restarted on Coumadin.
-Aspirin was added to your daily medication 325 mg daily.
You were discharged to a rehabiliatation facility.
Should you have any of the symptoms listed below or have any
symptoms concerning to you, please call your doctor or go to the
emergency room.
Followup Instructions:
Please follow up with your:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 86474**] [**Telephone/Fax (1) 40966**]. [**2197-1-26**] at 3:30pm.
NEUROLOGIST: Dr. [**Last Name (STitle) **] [**Hospital 878**] Clinic. Please call for an
appointment after discharged from rehab. [**Telephone/Fax (1) 2574**].
Completed by:[**2197-1-5**]
ICD9 Codes: 5070, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4636
} | Medical Text: Admission Date: [**2189-10-11**] Discharge Date: [**2189-10-14**]
Date of Birth: [**2142-5-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of breath and Diaphoresis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
47 yo F with h/o cardiomyapathy, schizoaffective disorder,
bipolar disorder, hypertension who was brought in by ambulance.
She complained of 2 hours of SOB and diaphoresis. EMS gave her
nitro Slx3, lasix and ASA. She had rales [**1-27**] way up, satting
80's on NRB, and hypotensive initially. VS were 74/42, HR 134, T
101.8, RR 40. ECG showed sinus tachycardia, vent bigeminy, STE
in V1-V4, STD with TWI in v5-v6.
She was intubated in the ED. Tox screen was negative. Labs
notable for slightly elevated WBC 11., HCO3 20, creat 1.4 (bl
1.1), CK 172, MB 4, Trop 0.02, lact 5.6. After intubation she
became hypertensive with SBP>200. She was given ASA, started on
nitro gtt and BPs were in 170's/90's. She was guaiac positive.
Past Medical History:
. Hypertension, poorly controlled.
2. Hypertrophic cardiomyopathy.
3. Left heart failure with a BNP of 4900 and EF of 50%.
4. Diabetes mellitus, type 2 uncontrolled with an A1c of 8.1.
5. Morbid obesity.
6. Iron deficiency anemia.
7. Epigastric pain, now resolved.
8. Schizo-affective disorder
9. CKD
Social History:
smokes free tobacco, drinks occasionally, remote marijuana use.
Lives in group living arrangement.
Family History:
no early cardiac deaths, diabetes mellitus, or hyperlipidemia
Physical Exam:
101.8, 88, 175/96, 25 on vent AC 500x18, PEEP 5, 100%
GENL: sedated, obese, unkempt
HEENT: JVP unable to be assessed given body habitus
CV: RRR no MRG
Lungs: Rales [**1-27**] way up
Abd: obese, soft, nontender, +BS
Ext: no edema, 2+ pedal pulses
Pertinent Results:
[**2189-10-10**] 10:53PM PLT COUNT-378
[**2189-10-10**] 10:53PM PT-12.6 PTT-24.6 INR(PT)-1.1
[**2189-10-10**] 10:53PM NEUTS-60.8 LYMPHS-32.9 MONOS-3.4 EOS-2.1
BASOS-0.7
[**2189-10-10**] 10:53PM WBC-11.8* RBC-4.72 HGB-11.6* HCT-36.7 MCV-78*
MCH-24.6* MCHC-31.6 RDW-20.7*
[**2189-10-10**] 10:53PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-10-10**] 10:53PM DIGOXIN-0.2*
[**2189-10-10**] 10:53PM HCG-<5
[**2189-10-10**] 10:53PM CK-MB-4 cTropnT-0.02* proBNP-4139*
[**2189-10-10**] 10:53PM LIPASE-21
[**2189-10-10**] 10:53PM ALT(SGPT)-14 AST(SGOT)-40 CK(CPK)-172* ALK
PHOS-86 AMYLASE-51 TOT BILI-0.5
[**2189-10-10**] 10:53PM GLUCOSE-292* UREA N-13 CREAT-1.4* SODIUM-134
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
[**2189-10-10**] 11:04PM LACTATE-5.6*
[**2189-10-11**] 12:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2189-10-11**] 12:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2189-10-11**] 12:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-10-11**] 12:35AM URINE HOURS-RANDOM
[**2189-10-11**] 02:38AM LACTATE-1.1 K+-3.2*
[**2189-10-11**] 02:38AM TYPE-ART PO2-278* PCO2-41 PH-7.41 TOTAL
CO2-27 BASE XS-1
[**2189-10-11**] 03:31AM PLT COUNT-307
[**2189-10-11**] 03:31AM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.7
[**2189-10-11**] 03:31AM CK-MB-10 MB INDX-5.8 cTropnT-0.31*
[**2189-10-11**] 03:31AM CK(CPK)-173*
[**2189-10-11**] 03:31AM GLUCOSE-235* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2189-10-11**] 03:31AM GLUCOSE-235* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2189-10-11**] 05:50AM HGB-10.0* calcHCT-30
[**2189-10-11**] 05:50AM K+-3.6
[**2189-10-11**] 05:50AM TYPE-ART PO2-109* PCO2-48* PH-7.37 TOTAL
CO2-29 BASE XS-1
[**2189-10-11**] 09:34AM PT-13.7* PTT-31.1 INR(PT)-1.2*
[**2189-10-11**] 09:34AM PLT COUNT-294
[**2189-10-11**] 09:34AM CK-MB-9 cTropnT-0.18*
[**2189-10-11**] 09:34AM CK(CPK)-223*
[**2189-10-11**] 10:58AM TYPE-ART PO2-161* PCO2-44 PH-7.37 TOTAL
CO2-26 BASE XS-0
[**2189-10-11**] 05:30PM HCT-28.6*
[**2189-10-11**] 05:30PM CK-MB-7
[**2189-10-11**] 05:30PM CK(CPK)-278*
[**2189-10-11**] 05:30PM POTASSIUM-3.7
[**2189-10-11**] 05:40PM TYPE-ART PO2-86 PCO2-45 PH-7.40 TOTAL CO2-29
BASE XS-1
.
P MIBI [**7-/2189**]: No anginal symptoms or ECG changes
from baseline. Fixed perfusion defects predominantly involving
the inferior and inferolateral walls. No evidence of reversible
perfusion defect. Mild LV hypokinesis, including likely akinesis
of the basal inferior wall, with a moderately depressed EF of
37%.
.
Echo [**7-/2189**]
Prominent symmetric LVH (septum 1.7 cm) with mild global
hypokinesis c/w diffuse process. Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**]
hypertension. Mild aortic regurgitation. No valvular [**Male First Name (un) **] or
resting LVOT gradient is identified. Findings are suggestive of
a primary cardiomyopathy (HCM) or possibly an infiltrative
process.
.
Bedside echo: no focal wall motion [**Last Name (LF) 16632**], [**First Name3 (LF) **] about 45%.
Brief Hospital Course:
A/P: 47 yo F with h/o HTN, schizoaffective disorder,
cardiomyopathy who presented with SOB, diaphoresis, hypotension,
respiratory distress and was subsequently intubated. The
following issues were investigated during this hospitalization:
.
CARDIAC
#Ischemia: Presenting symptoms were not likely due to ischemia
as CKs were flat and the Troponin elevation was minimal.
However, because the patient has CAD risk factors (HTN, DM), she
was maintained on her outpatient cardio-protective meds (ASA,
and Ace inhibitor) and a low dose statin was added.
.
# Pump: Pt. has a history of diastolic heart failure and can
thus benefit from beta blockade with resultant increased filling
time. She was started on Labetalol as an in-patient to control
both her hypertension and her heart rate. However, in an effort
to encourage medication compliance given the patient's history
of non-compliance, Labetalol was switched to QD Atenolol.
.
# Rhythm: Pt had atrial bigeminy on admission, but shortly
thereafter converted to normal sinus rhythm without further
incident.
.
# HTN: Pt. has poorly controlled HTN as an outpatient (200/100
daily, per caseworker) with known medication non-compliance. No
renal artery stenosis by imaging. During this hospitalization,
her goal SBP was 150-160, achieved with Labetalol gtt and
Labetalol PO. She was even found to sustain SBPs in the 130s.
The patient tolerated this lower BP well and was discharged on a
QD regimen of BP meds for better compliance.
.
# SOB: Likely flash pulmonary edema secondary to hypertensive
crisis on admission. Pt was intubated in the ED and extubated
the following day in the CCU without incident and continued to
saturate well on room air.
.
# Psych: Pt. has a history of schizoaffective disorder. She did
not give permission for her psych history to be disclosed so she
was only maintained on her outpatient regimen of Geodon and
Depakote with no other intervention. She also receives 100 mg
IM of Haldol every 3 weeks and received her scheduled injection
on discharge.
.
# Decreased UOP: Patient had a brief period of decreased urinary
output during the hospitalization, approximating 10-15ccs/hr.
Her creatinine also increased. She received a fluid bolus and
her I&Os were monitored with a goal of even fluid status.
Eventually, she began to autodiurese and her creatinine trended
downward. She was discharged on her outpatient dose of Lasix.
.
# DM: Patient was maintained on a RISS.
.
# Anemia: Pt. has a history of iron deficiency anemia and takes
iron as an outpatient. She was found to be guaiac positive on
NGL and rectally. Her Hct was at baseline during the
hospitalization. She was started on Pantoprazole [**Hospital1 **] and
continued on iron. Pt. will need a colonoscopy as an outpatient.
.
# Comm: [**Name (NI) **] [**Name2 (NI) 16633**]: [**First Name8 (NamePattern2) **] [**Name (NI) 16634**] - [**Telephone/Fax (1) 16635**],
cell-[**Telephone/Fax (1) 16636**] (9 AM - 5 PM).
Medications on Admission:
Nifedipine 60 mg tablets sustained release once a day
Aspirin 81 mg once a day
Lasix 20 mg once a day
Lisinopril 10 mg once a day
Glyburide 5 mg once a day
Ferrous sulfate 325 mg twice a day
Colace 100 mg twice a day
Geodon 100 mg [**Hospital1 **] (80 QAM, 20 QHS)
Depakote 500 mg [**Hospital1 **]
Haldol 100 mg IM Q3 weeks
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
Disp:*30 Capsule(s)* Refills:*2*
7. Ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
Disp:*30 Capsule(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
Disp:*30 Tablet(s)* Refills:*2*
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive emergency with pulmonary flash edema
Discharge Condition:
Stable, afebrile, saturating well on room-air.
Discharge Instructions:
1. Please take all medications as directed.
2. Please keep all follow-up appointments
3. Call your doctor or go to the ER for any of the following:
Chest pain, shortness of breath, fevers, chills or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-10-29**] 2:10
Provider: [**First Name8 (NamePattern2) 640**] [**First Name8 (NamePattern2) 16637**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-11-27**] 2:00
ICD9 Codes: 4280, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4637
} | Medical Text: Admission Date: [**2111-5-29**] Discharge Date: [**2111-6-4**]
Date of Birth: [**2032-5-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
toe debridement
History of Present Illness:
79 y/o female with a h/o T2DM, HTN, CAD, and atrial fibrillation
who presented to the ED from her vascular surgeon's office with
shaking chills/rigors. Of note, pt was hospitalized about 3
months ago at [**Hospital3 2358**] (unsure of what the diagnosis was).
In addition, pt receives all of her medical care at [**Hospital1 3343**]. Pt was in her USOH until 1-2 days ago when she developed
some chills. She did not take her temperature at home. Vitals
upon presentation to the ED: T 99.4 HR 90 BP 160/39 RR 16 94%RA,
FSBG 194. Pt was noted to be in atrial fibrillation with RVR (HR
140s) and symptomatic. Received vancomycin 1 g, levofloxacin 500
mg, and Flagyl 500 mg. Was given several boluses of IV diltiazem
and started on a diltiazem gtt. Also given ASA 325 mg and
Lopressor x 1. Vascular surgery saw the pt in the ED and
recommended cultures and continuing vanc/levo/flagyl for left
foot infection. Pt was transported to the MICU hemodynamically
stable.
.
ROS: Denies N/V/D or abdominal pain. Denies CP or SOB. Denies
frank fevers at home although some mild chills of late. No
urinary symptoms.
Past Medical History:
1. Atrial fibrillation, on AC
2. HTN
3. Hyperlipidemia
4. T2DM
5. Hypothyroidism
.
PSH:
s/p thyroidectomy
s/p hysterectomy
Social History:
Tobacco use for 47 yrs, 3 ppd. Quit over 10 yrs ago. No alcohol
or IVDU. Lives at home with her husband.
Family History:
Brother with [**Name (NI) 10322**].
Physical Exam:
T 98.8 BP 130/60 HR 107 RR 24 96% 4LNC
General: Comfortable. NAD.
HEENT: NC/AT. PERRLA. EOMI. MMM. OP clear.
Neck: No JVD or LAD.
CV: Irregularly irregular rhythm, no r/g.
Pulm: CTAB without wheezes or crackles.
Abd: Soft, obese, NT/ND with normoactive BS.
Ext: No c/c/e. 1+ DP B/L.
Skin: No rash. Evidence of erythema and purulent drainage in
left foot, 3rd toe.
Neuro: A/O x 3. CNs II-XII grossly intact. Good ROM and strength
in all 4 extremities.
Brief Hospital Course:
In the MICU pt was weaned off dilt drip and restarted on home
regimen of dilt and lopressor. She was seen by vascular surgery
for her lower ext wound they recommended foot x-ray and podiatry
consult. Podiatry debrided the wound and a wound swab was sent
for culture. She was put on empiric vanco/levo/metronidazole
for broad coverage of her wound infection. She was called out
to the floor on later that same day.
.
On the floor, her metoprolol and diltiazem were titrated up w/
good rate control of her atrial fibrillation.
.
Podiatry and vascular surgery continued to follow her. Her
wound culture grew Methicillin Sensitive S. Aureus. Her
antibiotic regimen was changed to Nafcillin only; she went to
the OR [**2111-6-2**] for debridement of the ulcer by podiatry. She was
stable for discharge home.
Medications on Admission:
Warfarin 7.5 mg ThSa, 5 mg MTWFSu
Mobic 15 mg daily
NTG PRN
Flecanide 100 mg [**Hospital1 **]
Metoprolol 100 mg [**Hospital1 **]
Glucophage/Glyburide 500/2.5 [**Hospital1 **]
Synthroid 125 mcg daily
Bumex 3 mg daily
Lisinopril 40 mg daily
Cartia XT 240 mg daily
chlordiazepoxide 25 mg QID (though pt taking "when I need it" -
when I get jittery)
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
6. Diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
Disp:*360 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
9. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
3rd left toe ulcer
Atrial fibrillation
.
Secondary:
Hypertension
Type II diabetes mellitus
Hyperlipidemia
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Please present to the hospital or call your primary care
provider if you have fever/chills, chest pain/shortness of
breath, or headache/dizziness.
.
You were in the hospital for an infection of your foot. You were
started on an antibiotic called dicloxicillin while you were in
the hospital. It is very important that you complete the course
of this medication.
.
While you were in the hospital, you had a fast heart rate. Some
of your heart medications were changed. Your dose of Metoprolol
was increased to 150mg twice daily. Additionally, a medicine
called diltiazem was started. This will replace your Cartia.
You will need to take the diltiazem 90mg four times per day.
.
Please follow up with your appointments and take all of your
medications as directed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2111-6-9**] 11:40
.
Please also plan to follow up with your primary care provider
within the next 2 weeks.
ICD9 Codes: 5990, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4638
} | Medical Text: Admission Date: [**2150-12-22**] Discharge Date: [**2150-12-24**]
Date of Birth: [**2131-9-1**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Morphine / Percocet / Dilaudid / Demerol
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
paradoxical vocal cord motion/stridor
Major Surgical or Invasive Procedure:
none
History of Present Illness:
19F with h/o ? asthma, depression, conversion disorder, and
paroxysmal vocal cord dysfunction (previous three [**Hospital1 18**]
admission (most recent [**11-22**], [**10-23**]) for previous episodes of
paradoxical vocal cord movement vs asthma flare requiring
intubation now presents with a third episode this year. This
weekend, she babysat and exposed to a baby who had a cold and
started having rhinorrhea/dry cough/sob/sore throat since
Sunday. Yesterday, when she was walking to class in cold, she
had what she believed was paradoxical vocal cord movement which
resolved when she arrived to a warm classroom. She believes that
her symptoms get triggered by URI, cold weather and exercise.
When she woke up this morning she started having symptoms again
and presented to Dr.[**Name (NI) 37129**] clinic. Per ED, Dr. [**Last Name (STitle) 3878**] noted
paradoxical vocal cord motion in his office and referred her to
ED for sedation to see if this might break the problem.
.
In the ER she received valium 5mg IV x1 but she became sedated
and dropped her oxygen saturation to the low 80/high 70%. She
was placed on Heliox. Her stridor continued. Panting has not
helped to break her symptoms. She was also evaluated by ENT who
scoped her and saw unremarkable vocal cord movement.
.
On ROS, she denies f/c, n/v, abdominal pain, diarrhea, urinary
or vaginal symptoms.
Past Medical History:
# Question asthma: Patient had been treated for asthma since
[**2148**], with home medications including prednisone, albuterol,
ipratropium, montelukast, and fluticasone. Additionally, pt had
been hospitalized for supposed asthma flares requiring
intubation. Supposed to have methacoline challange PFT as an
outpatient but hasn't been performed yet. Followed by Dr.
[**Last Name (STitle) 2171**].
# Paradoxical vocal fold dysfunction: Diagnosed per ENT
fiberoptic exam 9/[**2150**].
# Depression
# Conversion disorder: Per OMR notes recounting conversation
with
[**Hospital1 2025**] psychiatry ([**First Name8 (NamePattern2) **] [**Doctor Last Name **]), pt demonstrated fictitious
symptoms including asthma, hyperventilation, LOC [**3-20**]
hyperventilation, pseudo-seizures, and self-induced cellulitis.
Social History:
Social History:
# Professional: [**University/College **]nursing student.
# Personal: Lives in dormitory.
# Alcohol: None
# Tobacco: None
# Recreational drugs: None
Family History:
Pulmonary fibrosis (Grandmother), Father with died of MI at age
44.
Physical Exam:
96.7 83 143/89 20 100% on venti-mask Heliox, 99% on RA
GEN: Pleasant, awake, alert and in mild respiratory distress
with tachypnea but able to answer questions in full sentences
pretty comfortably. Cooperative with exam with no desaturations
noted. Stridor and high pitched voice (on heliox).
HEENT: PERRLA, EOMI, MMM with nonerythematous tonsils- slightly
enlarged. No OP lesions. No cervical LAD.
NECK: No JVD
HEART: RRR, nl S1, S2 without m/r/g
PULM: upper respiratory stridor at inspiration transmitting down
to the lungs but lower lung field clear, no wheezes, crackles,
rhonchi
ABD: soft, nt, nd, +BS
EXT: No edema, 2+ DP bilat
NEURO: AOX3, nonfocal
Pertinent Results:
[**2150-12-22**] 02:50PM BLOOD WBC-6.5 RBC-4.60 Hgb-13.4 Hct-37.3
MCV-81* MCH-29.2# MCHC-35.9*# RDW-16.7* Plt Ct-268
[**2150-12-23**] 04:02AM BLOOD WBC-6.6 RBC-4.54 Hgb-13.0 Hct-37.7 MCV-83
MCH-28.6 MCHC-34.5 RDW-16.8* Plt Ct-236
[**2150-12-22**] 02:50PM BLOOD Glucose-111* UreaN-9 Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-27 AnGap-13
[**2150-12-23**] 04:02AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-141 K-3.8
Cl-105 HCO3-25 AnGap-15
[**2150-12-23**] 04 :02AM BLOOD Calcium-9.8 Phos-4.4 Mg-2.4*
CXR [**2150-12-23**]: No evidence of cardiopulmonary pathology.
Brief Hospital Course:
A/P 19F with ? asthma and recurrent episodes of paradoxical
vocal
cord movement, depression and conversion disorder, now with
another paradoxical vocal cord dysfunction.
.
# Paradoxical vocal cord dysfunction: Pt was admitted to MICU in
a stable condition. Upon speaking to her PCP (Dr. [**Last Name (STitle) **],
paradoxical vocal cord dysfunction was likely a psychosomatic
manifestation. Her O2 sat was monitored closely and her O2 sats
remained in high 90s during her stridor episodes. Heliox was
weaned off. Since admission, pt had intermittent mild stridor
and dyspnea (complaining of throat closing up) with flushed face
which did not really respond to Heliox or nebs. With 1mg iv
ativan and reassurance, pt's strior improved and fell asleep
without stridor during sleep. ABG and even intubation was
considered upon admission, but given improvement after ativan,
it was held off. Her URI symptoms improved with pseudoephedrine
and Flonase and Afrin. Speech therapy evaluated the pt in am
and recommended continuing reassurance, treating nasal
congestion and GERD treatment. Psych was also consulted and
recommended continuing speech therpy and regular PROPHYLACTIC
visits to pt with ample reassurance. Also recommended using
Ativan 0.5-1mg po/im/iv/prn rather than Valium for
anxiety/agitation. Pt was discharged from ICU with weekly
follow-up with psych, ENT, Allergy, Speech, Pulmonary, and PCP.
.
# ?Asthma. Carries a diagnosis of asthma but unclear if [**3-20**] #1.
Pt was continued on all outpatient meds (Advair, singulair,
albuterol/atrovent nebs/prn). Pt has an appt with Pulmonary (Dr.
[**Last Name (STitle) 2168**] as outpatient with scheduled PFT.
.
# Allergies. Continued [**Doctor First Name 130**]/pseudoephedrine/flonase. Added
Afrin for 3 days for nasal congestion.
.
# Anemia. hct at baseline on admission. Continued outpt iron
supplement
.
# FEN. NPO initially given possibility of intubation. However,
as no intubation performed, pt was advanced to regular diet.
.
# PPX. sc heparin initially but d/ced as pt ambulated. continued
outpt ppi, bowel regimen
Medications on Admission:
Singulair 10mg po qday
Protonix 40mg po BID
Ferrous sulfate 325mg po qday
Flonase 50mcg 2 inhalation qam
Combivent 2 sprays q4h/prn
Allergra-D 240-180mg po qam
Advair Diskus 250mcg-50mcg inhalation [**Hospital1 **]
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) sprays
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
6. [**Doctor First Name **]-D 24 Hour 180-240 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as
needed for shortness of breath or wheezing for 1 weeks.
Disp:*8 Tablet(s)* Refills:*0*
8. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) for 2 days.
Disp:*1 inhaler* Refills:*0*
9. Flonase 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Nasal
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- paradoxical vocal cord motion
- upper respiratory infection
Secondary:
- asthma
- depression
Discharge Condition:
well
Discharge Instructions:
You were admitted to the intensive care unit with difficulty
breathing and URI-like symptoms. You were seen by ENT
physicians, psychiatry, and speech therapists. Your symptoms
improved and you were stable for discharge to home.
Please take all of your medications as previously instructed.
We also added afrin nasal spray to be used for three days. If
you have an acute episode of difficulty breathing, you can try
low-dose ativan which we have prescribed.
Please continue your breathing and relaxing exercises as these
helped improve your symptoms.
Please keep all your appointments.
Followup Instructions:
It is very important that you keep all of your followup
appointments. Please contact your PCP and psychiatrist to setup
an appointment within the next week. Also:
You have an appointment with your psychiatrist Dr. [**Last Name (STitle) **] on
Tuesday [**2150-12-29**]. Please keep your appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 3731**] Date/Time:[**2150-12-30**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30764**], MD Phone:[**Telephone/Fax (1) 1723**]
Date/Time:[**2151-1-6**] 3:45
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on [**2151-1-13**] at 11 am.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-1-26**] 11:10
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2168**] at 11:30a on [**2151-1-26**] after pulmonary
function test.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] at 9 am on [**2151-2-4**]
ICD9 Codes: 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4639
} | Medical Text: Admission Date: [**2158-3-2**] Discharge Date: [**2158-3-3**]
Date of Birth: [**2099-9-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Hypotension Diziiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo s/p CABGx3/ MV Repair [**2-14**] presents with hypotension,
tachycardia, crea 1.8 - no EKG changes but increased trop
(likely not significant as pt is asymptomatic and post op) Pt
seen by VNA who reported orthostatic hypotension (SBP 90's)and
tachycardia to 120's. Pt reports feeling dizzy with no appetite
over several days. Lopressor and lisinopril recently titrated
down. He states that he was taking Lopressor and Lisinopril
together, with a poor oral and fluid intake secondary to
dizziness. Pt reported feeling less lightheadedness after 1
liter NS. He denies CP, SOB, palpitations, diaphoresis. Due to
bump in troponin and recurrent hypotension, pt was admitted for
observation overnight and echo.
Past Medical History:
Hypertension
Hyperlipidemia
Silent MI
Moderate Mitral Regurgitation
TIA [**2155**]
Glaucoma
Sleep Apnea (does not use CPAP)
Renal insufficiency
[**2158-2-14**] coronary artery bypass x 3 (LIMA-LAD, SVG-OM, SVG-PLV),
Mitral valve repair (28mm ring)
[**2158-2-14**] coronary artery bypass x 3 (LIMA-LAD, SVG-OM, SVG-PLV),
Mitral valve repair (28mm ring)
Social History:
Lives with:alone
Occupation:service tech
Tobacco:1ppd x 25 years
ETOH:denies
Family History:
+CAD in parents and younger brother
Physical Exam:
VS: T 96.8 ST 101 148/71 R 22 99% RA
EKG: ST 114 RBBB old inferior infarct (unchanged from previous
EKG)
PE: Gen: AAOX3 in NAD
CVS: Sinus tachy + S1/S2
Lungs: CTA B/L
Abd: Soft NT ND + BS
Ext: Trace LE edema
Inc: C/D/I. Sternum stable
Labs: Hct 34.4 Crea 1.8 WBC 10 Plts 797 trop 0.17
Pertinent Results:
[**2158-3-3**] 03:09AM BLOOD WBC-8.3 RBC-3.28* Hgb-9.7* Hct-29.1*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.3 Plt Ct-653*
[**2158-3-2**] 04:20PM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2158-3-3**] 03:09AM BLOOD Glucose-106* UreaN-20 Creat-1.4* Na-140
K-4.4 Cl-111* HCO3-21* AnGap-12
[**2158-3-3**] 03:09AM BLOOD CK-MB-4 cTropnT-0.15*
[**2158-3-2**] 11:07PM BLOOD cTropnT-0.14*
[**2158-3-2**] 04:20PM BLOOD cTropnT-0.17*
[**3-3**] Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
inferior and very mild inferolateral hypokinesis. The remaining
segments contract normally (LVEF = 45%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. A mitral valve annuloplasty ring is
present. The gradient across the mitral valve is slightly
higher-than-expected (MG=6 mmHg at 84 bpm). There is no systolic
anterior motion of the mitral valve leaflets. An eccentric jet
of mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Well-seated mitrla annuloplasty ring with slightly
higher-than-expected gradients. Mild residual mitral
regurgitation. No pericardial effusion seen
Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old male who was admitted with
hypotension and dehyration. He was seen by VNA earlier and was
found to have orthostatic hypotension. He reports feeling dizzy
over the past several days, leading to decreased oral and fluid
intake. He presented to the ED with SBP 90's and ST in 120's.
After IV fluids, SBP 140's and he was asymptomatic. He was
admitted to the CVICU for 24 hour observation and a cardiac
echocardiogram to evaluate for pericardial effusion. Echo
showed EF unchanged, no pericardial effusion.
At the time of discharge, he was sinus rhtyhm in the 80's with
SBP 130's. He was instructed to take his Lopressor 50 mg [**Hospital1 **]
and Lisinopril at a separtate time. Oral and fluid intake were
encouraged, as well as Ensure as a supplement to meals. It was
felt that he was safe for discharge home with visiting nurse
services. Follow up appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
were scheduled.
Medications on Admission:
Lopressor 100 daily
Lisinopril 20 daily
Zantac
ASA
Zocor 40 daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Hypotension, Dehydration
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tylenol prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**3-23**] at 1:00 PM
Primary Care Dr. [**Last Name (STitle) **] in [**11-19**] weeks
Cardiologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-19**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-3-3**]
ICD9 Codes: 5859, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4640
} | Medical Text: Admission Date: [**2106-6-5**] Discharge Date: [**2106-6-15**]
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: Patient is an 89-year-old
gentleman with an extensive history of coronary artery
disease, who is status post myocardial infarction with known
peripheral vascular disease. He is also status post left
femoral to popliteal bypass graft in [**2105-12-11**].
He originally presented to the Emergency Department with a
history of increasing erythema and swelling of the left great
toe and forefoot one month prior to this admission. At that
time, he was admitted for one week and treated with IV
antibiotics. Plan was to discharge him to home and readmit
him at a later time for possible amputation.
On [**2106-6-5**], he returned with worsening symptoms on his left
foot. He denied any chest pain, shortness of breath, fever,
chills, diarrhea, or constipation. He does have significant
pain while ambulating. There is known increased erythema
around the left second toe, amputation site going up to his
mid calf.
PRIOR MEDICAL HISTORY:
1. Coronary artery disease status post PTCA and stent in
[**Month (only) 404**] of '[**05**].
2. AFib.
3. Rheumatic heart disease.
4. Renal cell carcinoma status post nephrectomy on right
side.
5. Hypothyroid.
6. Chronic renal insufficiency with creatinines ranging
between 2 and 3.
7. Glaucoma.
8. Status post colon cancer.
9. Myelodysplastic disorder with decreased platelet count.
PRIOR SURGICAL HISTORY:
1. Patient is status post left second toe amputation.
2. Status post left fem-[**Doctor Last Name **] bypass.
3. Status post abdominal aortic aneurysm repair.
4. Status post left lung lobectomy.
MEDICATIONS:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Levoxyl 200 mcg p.o. q.d.
3. Allopurinol 100 mg p.o. q.d.
4. Lasix 40 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Alphagan q.d.
8. Effexor XR 75 mg p.o. q.d.
9. Coumadin 2 mg p.o. q.d.
10. Dorzolamide 2% drops.
11. Flagyl 500 mg p.o. 3x a day.
12. Levofloxacin 250 mg p.o. q.d.
PHYSICAL EXAMINATION: On examination, patient's in general
is said to be well appearing. Pupils are equal, round, and
reactive to light. Cranial nerves II through XII are grossly
intact. Extraocular eye motions intact. Lungs are clear to
auscultation bilaterally. Cardiac is irregular without any
murmurs, rubs, or gallops. Abdomen is soft, nontender,
nondistended, normal bowel sounds. Left leg is said to be
erythematous, swollen to the mid calf. Pulse examination
shows 2+ radial pulses bilaterally, 2+ carotid pulses. No
evidence of any bruits. Femoral pulses are palpable
bilaterally. Dorsalis pedis is dopplerable. PT is
dopplerable and popliteal pulses are palpable.
BRIEF CLINICAL COURSE: On [**2106-6-5**], the patient was
admitted to the Vascular Surgery Service. At that time his
white blood cell count was 6.1, hematocrit 37.5, platelets
were noted to be decreased at 90. Coagulation studies were
PT of 19.5, PTT of 36.2, and INR of 2.5. Otherwise, his
laboratory results were unremarkable.
Blood cultures and wound cultures were collected at that time
and he was started on empiric therapy with Vancomycin,
levofloxacin, and Flagyl.
By hospital day four, the patient was continued on his triple
antibiotic therapy. Cellulitis was said to be stable without
any increase in inflammation. Throughout, patient was
afebrile and white count stayed within normal limits.
On hospital day five, the patient was preoped for a left
fem-[**Doctor Last Name **] bypass graft. The patient went smoothly on
[**2106-6-10**]. Patient was extubated without any complications.
However, was maintained in the PACU requiring Neo-Synephrine
and dobutamine drip requirement both intraoperative and
postoperatively. Over the night of postoperative day 0, the
patient's drips were able to be weaned from the
Neo-Synephrine and dobutamine, and patient was successfully
switched to dopamine.
On the morning of postoperative day one, the patient still
requiring dopamine infusion for blood pressure support.
Decision was made to transport him to the Surgical Intensive
Care Unit. In the Intensive Care Unit, patient was resumed
on his Levaquin and Flagyl. He did not require reintubation,
and did quite well until the night of postoperative day one
when he started having episodes of acidosis. Initial blood
gas showed a pH of 7.16, pCO2 of 41, pO2 70, gap -14. At
that time, the decision was made to reintubate the patient.
This proceeded without complication and the decision was made
to consult Cardiology service for further guidance on
maintaining blood pressure.
Cardiology consult recommended switching from dopamine to
Levophed which was indeed done. Subsequent workup showed no
evidence of ischemia. Decision was made to increase volume,
and once again, attempt to wean inotropic agents.
On postoperative day three, the patient was again doing well
and decision was made to extubate. He tolerated this well
with a post-extubation blood gas of 7.33, 48, 79, 26, and -1
on 6 liters mask.
Over the next few days, however, patient's mental status
continued to decline. He became increasingly confused and
blood gases showed increasing acidosis. In consultation with
the patient's daughter, wife, and brother, it became clear
that their wishes would be made DNR/DNI, and he be made
comfort measures only.
By [**2106-6-15**], the patient was showing increasing signs of
cardiogenic shock. Per the family's wishes, this was not
treated by the late afternoon of [**2106-6-15**], the patient was
having frequent episodes of brady systolic episodes and
hypotensive episodes and on [**2106-6-15**] at 16:40, ultimately was
announced had a systolic episode, and was pronounced dead.
Dr. [**Last Name (STitle) 1391**] was notified. Medical examiner was notified,
who declined examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2106-12-2**] 14:19
T: [**2106-12-2**] 14:18
JOB#: [**Job Number 32212**]
ICD9 Codes: 5185, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4641
} | Medical Text: Admission Date: [**2186-8-7**] Discharge Date: [**2186-8-11**]
Date of Birth: [**2117-1-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion and fatigue
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (21mm tissue) [**2186-8-7**]
History of Present Illness:
69 year female with history of rheumatic heart disease as a
child
and known aortic stenosis which has been followed by serial
echocardiograms. Recently she has noticed an increase in fatigue
and dyspnea on exertion. A recent echocardiogram showed moderate
to severe aortic stenosis with an aortic valve area of 0.8cm2.
Her valve is trileaflet. Given the progression of her symptoms
and significance of her aortic stenosis, she has been referred
to
Dr. [**Last Name (STitle) **] for surgical management.
Past Medical History:
Aortic stenosis
Rheumatic heart disease as child
Hypertension
Hyperlipidemia
Boderline diabetes
Arthritis
Obesity
Multiple (L) rib fractures as child with removal of a few ribs
Past Surgical History:
Left lower ribs removal
Social History:
Lives with: Boyfriend in [**Name2 (NI) 7661**]
Occupation: Seasonal taxes
Cigarettes: Smoked no [] yes [X] last cigarette 20 years ago Hx:
Smoked [**1-23**] ppd for 34 years.
Other Tobacco use:
ETOH: < 1 drink/week [X] [**2-28**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Family history of diabetes, stroke and hypertension
Physical Exam:
Vital Signs sheet entries for [**2186-7-12**]:
BP: 158/77. Heart Rate: 81. Resp. Rate: 16. O2 Saturation%: 100.
Height: 63" Weight: 190lb BSA 1.89m2
General: NAD
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benigh
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, III/VI SEM.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+[X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Right mid calf o/w suitable vein
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Transmitted murmur vs. Bruit
Pertinent Results:
[**2186-8-7**] Intra-op TEE:
Conclusions
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricle displays normal free wall contractility. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is moderate to severe aortic valve
stenosis (valve area 0.8 cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS There is normal global biventricular systolic
function. There is a bioprosthesis located in the aortic
position. It appears well seated. Theleaflets can not be seen.
No significant aortic regurgitation is noted. The maximum
pressure through the aortic valve was 27 mmHg with a mean
gradient of 13 mmHg at a cardiac output near 7 liters/minute.
The effective aortic valve area is in the range of 1.7 cm2.
Remaining valvular function appears unchanged. The thoracic
aorta is intact after decannulation.
.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2186-8-7**] where
she underwent an aortic valve replacement (tissue) with Dr.
[**Last Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
Post-operative day one found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on post-operative day four
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged to home in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Aspirin EC 81 mg PO DAILY
3. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*2
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg one tablet(s) by mouth
every four hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic stenosis
Rheumatic heart disease as child
Hypertension
Hyperlipidemia
Boderline diabetes
Arthritis
Obesity
Multiple (L) rib fractures as child with removal of a few ribs
Past Surgical History:
Left lower ribs removal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2186-9-27**] at 1:30PM
Cardiologist: [**Doctor Last Name 4922**] (office will call patient)
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 17354**],[**First Name3 (LF) **] [**Telephone/Fax (1) 17355**] in [**4-27**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2186-8-11**]
ICD9 Codes: 2724, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4642
} | Medical Text: Admission Date: [**2192-8-8**] Discharge Date: [**2192-8-16**]
Date of Birth: [**2140-11-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pollen Extracts / Bee Pollens
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Decreased vision in left eye
Major Surgical or Invasive Procedure:
Redo Mitral valve replacement
History of Present Illness:
Mr [**Known lastname 66797**] is a 51 year old man who under went minimally invasive
mitral valve replacement on [**2192-6-27**]. His post operative course
was uneventful except for a small right apical pneumothorax and
discharged on post operative day 4.
He had cough with sputum that his primary care physician treated
with zithromax. Then [**8-2**] noted decreased vision in his left
eye which was worked up by his primary care physician that
included an echocardiogram. The echo showed mitral
regurgitation with a possible leaflet stuck.
Admitted for redo mitral valve replacement
Past Medical History:
Mitral Valve Prolapse
Strepococcus endocarditis [**9-12**]
Hypertension
Hyperlipidemia
[**First Name9 (NamePattern2) 66798**] [**Location (un) **] [**2170**] - no residual
S/P Mitral Valve Replacement [**6-14**]
S/P Right Knee Surgery [**2191**]
S/P Oral Surgery [**2191**]
S/P Vasectomy
S/P Tonsillectomy and Adenoids
Social History:
He works as a consultant and lives with his wife.
[**Name (NI) 1139**]: none
Alcohol: occasional
Family History:
Coronary artery disease - father had a CABG at age 62.
Physical Exam:
Preop:
Vitals: Blood pressure 143/88, Heart Rate 88, Respiratory Rate
28, Oxygen Saturation 97% on room air, Temperature 97.2
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, Systolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, well perfused
Neuro: nonfocal
Discharge:
Vitals: T 99.4, BP 110/55, HR 100, RR 18 O2 Sat 95% on RA
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: normal range of motion, no JVD,
Lungs: clear bilaterally anterior and posterior
Heart: regular rate, normal s1s2 no murmur/rub/gallop
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, well perfused
Neuro: nonfocal
Psychiatric: pleasant and appropriate
Pertinent Results:
[**2192-8-16**] 07:20AM BLOOD WBC-14.9* RBC-3.58* Hgb-10.2* Hct-29.6*
MCV-83 MCH-28.5 MCHC-34.4 RDW-14.9 Plt Ct-500*
[**2192-8-14**] 03:11AM BLOOD PT-12.0 PTT-24.5 INR(PT)-1.0
[**2192-8-16**] 07:20AM BLOOD Glucose-140* UreaN-26* Creat-1.0 Na-135
K-4.3 Cl-95* HCO3-29 AnGap-15
CHEST (PA & LAT) [**2192-8-16**] 9:46 AM
CHEST (PA & LAT)
Reason: atelectasis improving?
[**Hospital 93**] MEDICAL CONDITION:
51 year old man s/p MVR
REASON FOR THIS EXAMINATION:
atelectasis improving?
TWO-VIEW CHEST X-RAY of [**2192-8-16**].
COMPARISON: [**2192-8-15**].
INDICATION: Status post mitral valve replacement. Reevaluate
atelectasis.
The patient is status post median sternotomy and mitral valve
surgery. Cardiac and mediastinal contours are stable in the
postoperative. Multifocal atelectasis involving the right middle
and both lower lobes shows overall interval improvement with
residual patchy and linear foci of atelectasis remaining. Small
right pleural effusion is without change.
IMPRESSION: Improving multifocal atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Prosthetic valve
function.
Status: Inpatient
Date/Time: [**2192-8-8**] at 16:41
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW04-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
INTERPRETATION:
Findings:
Pre-bypass TEE performed to assess prosthetic mitral valve
function. Three
dimensional reconstruction done with the TomTec computer system.
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body
of the LA. Probable thrombus in the LAA. All four pulmonary
veins identified
and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No mass or
thrombus in the RA
or RAA. No ASD by 2D or color Doppler. The IVC is normal in
diameter with
appropriate phasic respirator variation.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size. Low normal
LVEF.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Abnormal MVR
leaflet/disc motion. Increased MVR gradient.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo
contrast is seen in the body of the left atrium. A probable
thrombus is seen
in the left atrial appendage. No mass or thrombus is seen in the
right atrium
or right atrial appendage. No atrial septal defect is seen by 2D
or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the descending thoracic aorta. There are three
aortic valve
leaflets. The aortic valve leaflets are mildly thickened. No
aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present.
Motion of the prosthetic mitral valve leaflets/poppet is
abnormal. The
gradients are higher than expected for this type of prosthesis.
There is no
pericardial effusion.
There is an echo dense mass on the atrial side of the mitral
prosthesis, which
is leading to restricted leaflet motion and mitral regurgitation
jet of
moderate intensity. Three dimensional reconstruction was done to
show it to be
the prosthetic valvular holding mechanism. It was associated
with a calculated
mitral valve area of 0.9cm2. There is also possible thrombus
formation on the
left atrial side of the prosthesis. Left atrial appendage was
free of clot and
had good ejection velocity.
POST BYPASS:
[**Last Name (Prefixes) **] biventricular systolic function.
Bioprodthesis in mitral posiiton. Well seated and mechanically
stable. Trace
MR and no signofocant gradient. No other change.
POST CPB: A bioprosthesis is visualized in the mitral position.
Functionally
stable and has good leaflet excursion. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 66799**]r
systolic function with background inpotropic support.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2192-8-11**] 22:11
Brief Hospital Course:
Mr [**Known lastname 66797**] was admitted directly to the cardiac surgery recovery
unit for pre operative work up and then was transferred to the
operating room on [**2192-8-8**]. Please see operating room
report for full details. In summary, he had a mitral valve
replacement(29mm CE Pericardial) via sternotomy.
He tolerated the operation well and was transferred to the
cardiac surgery recovery unit. At the time of transfer he was
on epinephrine, neosynephrine, and propofol. He did well in the
immediate post operative period and was weaned from the
epinephrine, neosynephrine, and propofol. The anesthesia was
reversed and he was successfully weaned from the ventilator and
extubated.
On post operative day 1, he remained in the cardiac surgery
recovery unit for aggressive diuresis, pain management and
management of hypertension.
On postoperative day [**1-15**], continued with aggressive diuresis,
transfused with packed red blood cell for hematocrit 21, pain
management, chest tube and epicardial wires removed. He also
required aggressive respiratory therapy.
Postoperative day 6 he was transfered to the floor and continued
to progress and was discharged home with services on post
operative day 7.
Medications on Admission:
Lopressor 50mg twice a day
Aspirin 325mg twice a day
Lipitor 40mg daily
Zitromax - completed just prior to admission
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day: 20 meq [**Hospital1 **] x
1week then 20meq QD x 10 days.
Disp:*48 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: 40 mg
[**Hospital1 **] x 7 days then 40mg QD x10 days.
Disp:*24 Tablet(s)* Refills:*0*
7. Protonix 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*
8. Glucosamine 500 mg Tablet Sig: as directed Tablet PO once a
day: resume preop schedule.
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Redo Mitral valve replacement (#29 CE pericardial)
PMH: Mitral valve prolapse, Mitral valve replacement, s/p
[**Location (un) 30065**]-[**Location (un) **] '[**70**], Hypertension, elevated cholesterol,
Endocarditis, Right knee [**Doctor First Name **], Tonsillectomy and adenoids,
Vasectomy
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr [**Last Name (STitle) 37063**] in [**1-13**] weeks(pt to call for appt)
Dr [**Name (NI) **] in 4 weeks(pt to call for appt [**Telephone/Fax (1) 1504**])
Completed by:[**2192-8-17**]
ICD9 Codes: 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4643
} | Medical Text: Admission Date: [**2188-9-8**] Discharge Date: [**2188-9-10**]
Date of Birth: [**2131-1-27**] Sex: F
Service:
AGE: 57.
HISTORY OF THE PRESENT ILLNESS: This is a 57-year-old
Caucasian female with past medical history significant for
coronary artery disease status post angioplasty of the LAD in
[**2179**], who now presents with acute chest pain consistent with
acute inferior ST elevation myocardial infarction. The
patient reports being in good health until the morning of
[**9-7**], when she developed a headache and slight
discomfort between her shoulder blades. This pain was
transient in nature and relieved by Advil. Around 8 PM that
same day she developed crushing substernal chest pain,
nonradiating in nature, 10 out of 10 in intensity, more
severe then any chest pain she had had in [**2179**], associated
with diaphoresis, nausea, and arm heaviness bilaterally. She
was taken to [**Hospital3 3583**] via ambulance and EKG there
revealed sinus bradycardia at a rate of 53 with normal axis
and intervals. There was 1-mm ST elevations in all her
inferior leads, reciprocal ST depressions and T-wave
inversions in 1 and AVL. As a result, she was given IV
nitroglycerin, heparin, morphine, and Aspirin and she was
immediately given [**Location (un) **] to [**Hospital1 188**] for emergent catheterization. Cardiac catheterization
demonstrated total occlusion of her distal right coronary
artery and three stents were placed without any
complications. She was then admitted to the Coronary Care
Unit for overnight observation. She arrived on the unit in
stable condition and without any complaints. She denied any
chest pain, nausea, vomiting, shortness of breath,
diaphoresis, jaw pain, arm pain, lightheadedness, or
dizziness.
PAST MEDICAL HISTORY: History revealed coronary artery
disease status post angioplasty in [**2179**] of an LAD lesion,
diagnosed via nuclear scan. She denies any history of
hypertension, diabetes mellitus, or hypercholesterolemia.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Atenolol.
ALLERGIES: The patient is allergic to ERYTHROMYCIN,
PENICILLIN, both resulting in hives; MORPHINE RESULTS IN
NAUSEA/VOMITING.
FAMILY HISTORY: The maternal grandfather died of a
myocardial infarction at the age of 49. Father died of a
myocardial infarction at the age of 62. Mother had a
coronary artery bypass graft times three in her early 60s.
Brother had an angioplasty of his LAD in his early 50s.
SOCIAL HISTORY: The patient has a ten pack per year tobacco
history. She quit in [**2179**]. She drinks alcohol occasionally
and denies any history of intravenous drug abuse. She is a
former nurse [**First Name (Titles) **] [**Hospital3 3583**]. She is divorced currently
with one daughter who is 37 weeks pregnant at the moment,
hospitalized at [**Name (NI) 46**] with preeclampsia. She is scheduled
for a cesarean section later on this week.
REVIEW OF SYSTEMS: Review of systems revealed the following:
The patient is positive for mild diarrhea, poor appetite, and
increased amount of stress secondary to her daughter's
current health. Otherwise, review of systems is
unremarkable.
Examination on admission: Temperature 96.3, blood pressure
99/51, pulse 88, respirations 18, 98% oxygen saturation on
two liters nasal cannula. GENERAL: The patient is a
pleasant, middle-aged Caucasian female, who is comfortable,
pain free, talkative, but tired in no acute distress. Pupils
equal, round, and reactive to light. EOMI. Sclerae were
anicteric. Nares patent. Oropharynx clear without any
exudate or lesions. Mucous membranes are slightly dry.
NECK: Revealed no JVD, no carotid bruits, no thyromegaly.
Neck was supple and nontender. LUNGS: Lungs were clear to
auscultation anteriorly, bilaterally. CARDIOVASCULAR:
Regular rate and rhythm with no audible rubs, murmurs, or
gallops. ABDOMEN: Soft, nontender, nondistended with normal
bowel sounds. There are no palpable masses and no
hepatosplenomegaly. EXTREMITIES: Extremities are without
any clubbing, cyanosis, or edema. Toes are cool bilaterally
with Dopplerable dorsalis pedis pulses bilaterally. There is
no evidence of calf tenderness. The calf site of the right
groin is without any hematoma or oozing of blood.
LABORATORY DATA: Labs on admission revealed the following:
White count 10, hemoglobin 12, hematocrit 36, platelet count
405,000, sodium 140, potassium 4.1, chloride 106, bicarbonate
23, BUN 11, creatinine 0.9, glucose 117. CK 107, LDH 631,
troponin negative. Post cardiac catheterization EKG reveals
ST elevations in the inferior leads with ST depressions in 1
and AVL, normal sinus rhythm at 92, normal axis, and normal
intervals.
HOSPITAL COURSE: Ms. [**Known lastname **] was brought up from the
cardiac catheterization laboratory to the Coronary Care Unit
for overnight observation. She was immediately started on
aspirin, Plavix, Pravachol, Metoprolol 25 t.i.d. and an
Integrilin drip for a total duration of 18 hours. The
cardiac enzymes were cycled every eight hours. CK was found
to peak at 1673 at 10 am on [**9-8**]. Similarly, the MB
peaked at 307 at the same time. Echocardiogram was performed
on [**9-9**] and revealed hypokinetic basilar inferolateral
walls with EF of 45%, 1+ mitral regurgitation, no pericardial
effusion and normal size of all [**Doctor Last Name 1754**].
With the exception of her blood pressure running a little on
the low side and occasional beats of nonsustained V tach on
telemetry, Ms. [**Known lastname **] remained stable throughout the night,
status post the catheterization. It was decided to transfer
her to the Cardiac Stepdown Unit during the morning of
[**9-8**]. As soon as she reached the floor, she had a
large episode of coffee-ground and bright red blood emesis.
As a result, the Integrilin drip was immediately discontinued
and because the blood pressure dropped further, the
Metoprolol was also discontinued. GI consultation was called
and it was decided to perform an emergent endoscopy only if
further emesis occurred. The thought was that Ms. [**Known lastname 39597**]
use of chronic aspirin had resulted in an underlying
gastritis/ulcer, which had been exacerbated by recent
anticoagulation therapies. Because she had no further
episodes of emesis, she was managed medically throughout the
hospital stay. She was kept NPO for 24 hours and serial
hematocrits were checked every six hours. The lowest the
hematocrit dropped was to 27.9 and as a result, she was
transfused one unit of packed red blood cells. She was
started on IV Protonix 40 b.i.d. as well as IV fluids at
75 cc an hour. Electrolytes were checked on a daily basis
and the potassium was kept above 4. The magnesium was kept
above 2. Fortunately, she had no further episodes of emesis
and the hematocrit remained stable, hovering around 30 to 31
status post one unit transfusion. She was advanced to clears
on the night of [**9-9**] and then to a full cardiac diet on
[**9-10**]. The IV Protonix was changed to PO. The
Metoprolol was restarted at 25 b.i.d. Because she remained a
little on the hypotensive side with blood pressure running in
the 100s/70s, it was decided not to start an ACE inhibitor at
this point in time. She was completely asymptomatic with
this blood pressure. Orthostatics were checked and negative.
Because the random glucose level was elevated on [**9-8**],
a hemoglobin A1c level was checked. This level is currently
pending. The creatinine remained stable throughout her stay
at 0.6 and the urine output remained excellent. She remained
afebrile throughout her stay, but with a leukocytosis most
likely secondary to trauma in the cardiac catheterization
lab/recent myocardial infarction.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg PO b.i.d.
2. Folic acid 1 mg PO b.i.d.
3. Pravachol 20 mg PO b.i.d.
4. Plavix 75 mg PO q.d.
5. Aspirin 325 mg PO q.d.
6. Metoprolol 25 mg PO b.i.d.
DISCHARGE DIAGNOSES:
1. Acute ST elevation inferior myocardial infarction status
post three stents in the right coronary artery.
2. Upper GI bleed most likely secondary to gastritis/ulcer.
3. Anemia.
DISCHARGE INSTRUCTIONS:
1. The patient is to be transferred on [**9-10**], to [**Hospital3 6265**]. She is to have a bed on the regular medicine floor
with telemetry monitoring. The reason for this transfer is
that her daughter recently gave birth to twin boys under
emergent cesarean section at [**Hospital3 3583**] and the patient
wishes to be closer to her daughter at this time.
Attending at [**Hospital1 46**] will be Dr. [**First Name (STitle) **], a physician who
knows her personally and has followed her on an outpatient
basis. She is to have a full upper endoscopy study in six to
eight weeks to evaluate gastric/peptic ulcer. If she is to
have further episodes of gross emesis, emergent endoscopy may
be done. She is to remain at [**Hospital3 3583**] until necessary
for post MI observation and titration of her cardiac
medications.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-269
Dictated By:[**First Name (STitle) 35062**]
MEDQUIST36
D: [**2188-9-10**] 12:16
T: [**2188-9-10**] 13:30
JOB#: [**Job Number 39598**]
ICD9 Codes: 2851, 4240, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4644
} | Medical Text: Admission Date: [**2143-8-28**] Discharge Date: [**2143-8-31**]
Date of Birth: [**2081-7-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62y/o F with COPD and alcohol abuse transfered from [**Hospital1 **]
for DT/EtOH withdrawal. She was admitted to [**Hospital1 **] two days
ago. She complained of increasing shakes and nausea there. She
had 3-4 episodes of non-bloody vomiting. She also compained of
diaphoresis and agitation. She denies any head trauma, other
ingestions such as Tylenol, or any body injuries.
She reports occasional drinking until [**2139**], when she gradually
started to increase her intake. About a year ago, she was
drinking one pint of vodka daily. She was admitted to a
hospital with EtOH-related hepatitis and jaundice. She was then
sober for about 8 months and started drinking agian.
In the ED, initial vs were: 98.4 140 124/76 20 95/RA. She was
tremouls, tacycardic, hypertensive, diaphoretic, anxious, and
agitated. CIWA peaked at 19, and was 19 prior to trasfer.
Patient was alert, confused. She was noted to be wheezing. Tox
screen negative. CXR unremarkable. EKG with sinus tach. No
head CT as no concern for head bleed. Patient was given 2L NC
oxygen, Ipratropium, Lorazepam 2mg, MethylPREDNISolone 125mg,
Bannana bag, Diazepam 10 mg. Prior to trasnfer, 143/77 90 20
97/2L
.
On the floor, she continues to be shakey, but feels generally
well and wonders when she can go back to [**Hospital1 **].
.
Review of systems:
(+) Subjective fevers, chills, dry cough, mild headache today
that is now resolved, rhinorrhea, dyspnea at baseline,
palpitations, and as per HPI.
(-) Denies recent weight loss or gain, chest pain or tightness.
Denied diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
COPD
[**Doctor Last Name 933**]
EtOH related hepatitis - admitted in [**2142**] with jaundice
Social History:
Smoked 1 ppd x 40 years, alcohol as above, denies illicit drug
use. Lives with husband. Formerly from [**Doctor First Name 5256**]. Not
currently working.
Family History:
Father died from alcoholism.
Physical Exam:
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI. No
lid lag, no exopthalmos.
Neck: supple, JVP not elevated, no LAD. Palpable large thyroid.
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. No caput
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: a/ox3, CNs [**3-21**] intact, strength and sensation intact
throughout. No asterixis.
skin: no spider angiomas seen
Pertinent Results:
Labs on Admission: [**2143-8-28**]
WBC-6.6 RBC-4.67 Hgb-14.7 Hct-42.6 MCV-91 MCH-31.4 Plt Ct-95*
Neuts-47* Bands-0 Lymphs-41 Monos-7 Eos-5* Baso-0 Atyps-0
Metas-0 Myelos-0
PT-13.0 PTT-24.9 INR(PT)-1.1
Glucose-176* UreaN-7 Creat-0.6 Na-140 K-3.7 Cl-102 HCO3-24
AnGap-18
ALT-132* AST-102* CK(CPK)-123 AlkPhos-126* TotBili-0.6
Calcium-9.2 Phos-2.7 Mg-1.7
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
HCV Ab-PND
.
T4-8.5 T3-147
[**2143-8-29**] 05:28AM BLOOD Free T4-2.0*
TSH-LESS THAN 0.02
.
.
.
[**2143-8-28**] CXR: No acute cardiopulmonary process.
.
Labs at discharge:
.
[**2143-8-31**] 08:00AM BLOOD WBC-9.6 RBC-5.08 Hgb-15.5 Hct-47.5 MCV-94
MCH-30.6 MCHC-32.7 RDW-13.7 Plt Ct-129*
[**2143-8-31**] 08:00AM BLOOD Neuts-53.9 Lymphs-32.0 Monos-6.2 Eos-7.5*
Baso-0.4
.
[**2143-8-31**] 08:00AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.1
.
[**2143-8-31**] 08:00AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-16
.
[**2143-8-31**] 08:00AM BLOOD ALT-135* AST-104* LD(LDH)-250
AlkPhos-125* TotBili-0.9
.
[**2143-8-28**] 01:45PM BLOOD HCV Ab-NEGATIVE
[**2143-8-28**] 01:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
Brief Hospital Course:
This is a 62 year old female with a history of COPD and EtOH
dependence presenting with alcohol withdrawal.
.
# EtOH WITHDRAWAL: We treated the patient with multivitamin,
folate, thiamine, and 1L IVF. She also received Valium 10mg prn
CIWA > 10. Overnight in the ICU, she received a total of 20mg of
valium. Social work was also consulted. Since the night of
admission, she did not require benzodiazepines, only occasional
zofran for nausea. She was transferred to the floor, and
required no benzodiazepines there. We had hoped that she would
return to [**Hospital1 **] for continued detox, however the patient
was adamant on returning home, which we obliged.
.
.
# COPD: Somewhat wheezy on admission, but no evidence for acute
exacerbation. Currently asymptomatic and moving good air. The
patient was on standing nebs and fluticasone. She remained
asymptomatic throughout her stay and was discharged on her home
meds.
.
# Emesis: No history of blood and guiac negative. We monitored
her hematocrit which was stable. Nausea was treated with Zofran
prn.
.
# Elevated liver function tests: ALT>AST atypical for
alcohol-related liver disease. Unclear if acute vs chronic,
given prior history. Low platelets suggest chronic process.
Hepatic serologies were all negative. We monitored her liver
function tests, which were relatively stable. After consulting
endocrine, we attributed this to her thyrotoxicosis, which can
cause a transient transaminitis. Likely also an element of
alcoholic hepatitis.
.
# History of [**Doctor Last Name 933**]: The patient stated that she was treated
with radioactive iodine and she has not taken any medication for
her [**Doctor Last Name **] for some time. A TSH was not measurable. While her
total T4 and T3 are normal, Free T4 was elevated. In the
context of tachycardia, her endocrinologist from home was c/s
and he wanted to restart her on methimazole 10mg PO BID and also
propanolol 10mg [**Hospital1 **]. She was discharged on 20 mg of methimazole
qd and propranolol, with follow up in 1 week to check her LFTs
and blood counts (due to risk of agranulocytosis with
methimazole).
.
# Code: confirmed full
.
# Communication: Patient and husband [**Name (NI) 23081**] ([**Telephone/Fax (1) 83107**]
.
# Disposition: home
Medications on Admission:
CombiPatch dose unknown
Lorazepam 0.5 mg ? as needed
Ambien 2.5 mg PO HS:PRN Sleep
Discharge Medications:
1. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
3. Estradiol-Norethindrone Acet 0.05-0.14 mg/24 hr Patch
Semiweekly Sig: One (1) Patch Semiweekly Transdermal every
seventy-two (72) hours.
4. Methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qhs prn as
needed for insomnia.
6. Ambien Oral
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol Withdrawal
2. Hyperthyroidism
Discharge Condition:
Good
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted with symptoms of alcohol withdrawal and
treated appropiately with benzodiazepines. Further testing also
revealed changes in your Grave's Disease, which may have also
contributed to your symptoms. You were seen by endocrinologists
here that agreed with your outpatient endocrinolgist that you
should restart methimazole. Your new medications here were
methimazole 20mg PO daily and propanolol 10mg PO daily. You
also indicated that you wished to quit smoking, so you were
prescribed a nicotine patch. Methimazole can have side effects
of decreasing your white blood cells. If you have symptoms of
fevers, you should stop the methimazole immediately and go to a
lab to have your blood drawn as per Dr.[**Name (NI) 83108**]
instructions.
We are concerned about your drinking habits, and we hope that
you will continue to seek treatment concerning this. It is
likely that you are drinking as a means to cope with difficult
events in your life, however drinking is not a productive means
of coping. It is important that you seek help with both your
drinking and the events in your life that you find difficulty
coping with, in the form of therapy or meetings with alcoholics
anonymous.
Followup Instructions:
Follow up with your primary care doctor within one to two weeks
of discharge.
.
You have a follow up appointment with Dr.[**Last Name (STitle) **] (your
endocrinologist) as below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2143-9-18**] 2:00
.
Dr.[**Last Name (STitle) **] has given you a prescription to check your lab
workup on [**2143-9-11**]. Please ask the lab to fax the
results to [**Telephone/Fax (1) 83109**].
Completed by:[**2143-9-3**]
ICD9 Codes: 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4645
} | Medical Text: Admission Date: [**2176-2-21**] Discharge Date: [**2176-2-25**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
female with limited stage small cell lung cancer who was
treated with three cycles of carboplatin/etoposide and
concurrent radiation therapy completed in [**10-24**]. Treatment
course was complicated by pneumonia and her fourth course of
chemotherapy was held. She did relatively well until [**12-24**]
when she complained of headache. Temporal artery biopsy was
performed and was negative, so she was put on prednisone
taper.
More recently, she has been complaining of decreased
appetite, increased shortness of breath, nausea, and
vomiting. Laboratory work included increased LFTs. CT scan
torso yesterday revealed a large pericardial effusion from an
epi-pericardial mass resulting in right heart failure. She
was electively admitted for management of pericardial
effusion.
PAST MEDICAL HISTORY:
1. Congestive obstructive pulmonary disease.
2. Coronary artery disease status post myocardial infarction
and PTCA with stent placement.
3. Chronic lower back pain.
4. Small cell lung cancer.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levoxyl 75 mg po q day.
2. Paxil 30 mg po q day.
3. Enalapril 5 mg po q day.
4. Diazepam 3 mg po q day.
5. Zocor 40 mg po q day.
6. Trazodone 50 mg po q day.
7. Roxicet one teaspoon prn.
8. Megace 400 mg po q day.
PHYSICAL EXAM ON ADMISSION: Temperature 96.9, blood pressure
of 86/palp, heart rate in the 90s, respiratory rate 16,
sating well on room air. In general, she is a thin female in
bed. HEENT: Oropharynx is clear. Neck is supple.
Cardiovascular: Sinus tachycardia, faint S1, S2. Lungs:
Coarse breath sounds, otherwise clear. Abdomen is soft with
mild tenderness. Extremities: No lower extremity edema.
LABORATORY VALUES ON ADMISSION: White blood cell count of
10.6, hematocrit of 38.1, platelets of 310. Sodium of 132,
potassium of 4.6, chloride 96, CO2 22, BUN of 27, creatinine
1.1. Glucose 142, INR of 1.4.
HOSPITAL COURSE BY SYSTEM: The patient was transferred to
the CCU from OMED for elective pericardial centesis. A
pericardial centesis was performed by under normal
procedures, which removed immediately 600 mL of
serosanguinous fluid followed by an additional 4-500 cc over
the next 48 hours.
The pericardial drain was left in place until drainage was
less than 100 cc per day. It was removed, and the patient
was transferred to the Medicine Service in good condition.
The patient's symptoms improved markedly with drainage of
pericardial effusion. She remained in chronic asymptomatic
tachycardia, however, even after drainage of the effusion.
Oncology: Patient and family decided at this time they did
not wish to undergo further chemotherapy and that she would
be made DNR/DNI, and brought home as a bridge to hospice.
DISCHARGE DIAGNOSES:
1. Small cell lung cancer.
2. Pericardial effusion.
3. Pericardial tamponade.
4. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Diazepam 1 mg po q day.
2. Vitamin D 400 units po q day.
3. Calcium carbonate 500 mg po tid.
4. Prednisone 5 mg po q day.
5. Senna two tablets po q hs.
6. Docusate 100 mg po bid.
7. Lactulose 30 mg po q6 prn.
8. Protonix 40 mg po q day.
9. Aspirin 81 mg po q day.
10. Percocet 1-2 tablets q4-6h prn.
11. Trazodone 50 mg po q hs.
12. Simvastatin 40 mg po q day.
13. Peroxitine 30 mg po q day.
14. Levothyroxine 75 mcg po q day.
DISPOSITION: She was discharged in stable condition to home.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13111**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2176-2-25**] 10:47
T: [**2176-2-26**] 13:30
JOB#: [**Job Number 13112**]
ICD9 Codes: 9971, 496, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4646
} | Medical Text: Admission Date: [**2191-4-30**] Discharge Date: [**2191-4-30**]
Date of Birth: [**2160-5-22**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Liver laceration
Major Surgical or Invasive Procedure:
Bedside ex-lap
Bedside clam shell thoracotomy
Bedside Pericardial window
History of Present Illness:
30yM transfered from [**Hospital6 **] s/p single stab wound
to the abdomen. At the OSH, the patient was taken to the OR for
ex-lap and was found to have an 8cm deep laceration of the right
lobe of his liver which they sutured. Per report, EBL was
estimated to be 5 liters and required ~14u PRBC, platelets, and
ffp. They then found that branches of the portal vein and
hepatic artery were bleeding so they packed his abdomen and
closed for transfer to [**Hospital1 18**]. In the PACU of OSH, the patient
was unstable and required further blood product transfusions.
Eventually, the blood pressure was reported to be ~120/80 with a
hct of 25 so the patient was transfered to [**Hospital1 18**]. No temp was
recorded at OSH. Upon arrival to [**Hospital1 18**] BP was 80/p, T was 88F,
and the patient was brought directly to the TSICU.
Past Medical History:
Unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
Intubated and sedated
Active bleeding from nares and into abdominal JP drain
Anasarcatous
RIJ in place
Abdominal JP in place with BRB
Pertinent Results:
[**2191-4-30**] 07:25AM TYPE-ART PO2-56* PCO2-106* PH-6.81* TOTAL
CO2-19* BASE XS--22
[**2191-4-30**] 07:25AM GLUCOSE-195* LACTATE-7.8* K+-4.5
[**2191-4-30**] 07:25AM freeCa-0.95*
[**2191-4-30**] 06:26AM TYPE-ART PO2-237* PCO2-65* PH-6.92* TOTAL
CO2-15* BASE XS--21
[**2191-4-30**] 06:03AM GLUCOSE-262* UREA N-7 CREAT-0.9 SODIUM-149*
POTASSIUM-4.6 CHLORIDE-117* TOTAL CO2-14* ANION GAP-23*
[**2191-4-30**] 06:03AM CALCIUM-8.5 PHOSPHATE-8.3* MAGNESIUM-1.5*
[**2191-4-30**] 06:03AM WBC-8.7 RBC-2.99* HGB-9.1* HCT-27.9* MCV-94
MCH-30.5 MCHC-32.6 RDW-14.0
[**2191-4-30**] 06:03AM PLT COUNT-103*
[**2191-4-30**] 06:03AM PT-21.2* PTT-150* INR(PT)-2.0*
[**2191-4-30**] 06:03AM FIBRINOGE-62*
[**2191-4-30**] 05:27AM TYPE-MIX PO2-222* PCO2-70* PH-6.85* TOTAL
CO2-14* BASE XS--23 COMMENTS-GREEN TOP
[**2191-4-30**] 05:27AM LACTATE-5.8*
[**2191-4-30**] 05:27AM freeCa-1.07*
[**2191-4-30**] 05:19AM TYPE-ART PO2-169* PCO2-65* PH-6.89* TOTAL
CO2-14* BASE XS--22
[**2191-4-30**] 05:19AM GLUCOSE-221* LACTATE-5.6*
[**2191-4-30**] 05:19AM freeCa-1.09*
[**2191-4-30**] 04:56AM GLUCOSE-269* UREA N-6 CREAT-1.0 SODIUM-145
POTASSIUM-4.6 CHLORIDE-118* TOTAL CO2-13* ANION GAP-19
[**2191-4-30**] 04:56AM estGFR-Using this
[**2191-4-30**] 04:56AM ALT(SGPT)-1201* AST(SGOT)-[**2170**]* ALK PHOS-77
AMYLASE-49 TOT BILI-0.3
[**2191-4-30**] 04:56AM LIPASE-31
[**2191-4-30**] 04:56AM ALBUMIN-1.8* CALCIUM-9.0 PHOSPHATE-9.3*
MAGNESIUM-1.7
[**2191-4-30**] 04:56AM WBC-14.6* RBC-3.89* HGB-11.3* HCT-35.1*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.5
[**2191-4-30**] 04:56AM PLT COUNT-86*
[**2191-4-30**] 04:56AM PT-37.0* PTT-150* INR(PT)-4.0*
[**2191-4-30**] 04:56AM FIBRINOGE-61*
Brief Hospital Course:
On arrival into our intensive care unit the patient was found to
be profoundly hypothermic with a core body temperature of 88
degree Fahrenheit. He was profusely
bleeding from the abdomen, the nares and the orogastric tube. An
arterial blood gas showed a pH of 6.8. He as aggressively
resuscitated with fluids, packed red blood cells, fresh frozen
plasma, platelets, cryoprecipitate and many attempts at warming
using a Bair Hugger device, that and room heating were
performed. The patient's core temperature eventually reached
34.9 degrees, but he became progressively more
difficult to ventilate. CXR done on admission was unremarkable,
however, when the patient had increased difficulty ventilating,
bilateral tube thoracotomies were performed. From the right
chest tube, the patient had sanguinous discharge. He had
continued difficulty with ventilation, and at this point his
abdomen was quickly prepped and the retention sutures from his
prior surgery were removed and patient was eviscerated.
Next, the patient became somewhat easier to ventilate, however,
his oxygen saturation continued to deteriorate and the patient
became bradycardic, eventually displaying only agonal complexes
with no blood pressure. The patient had
bilateral chest tubes that had been placed previously, but there
was blood clotted in the right chest tube. The team was
concerned that the patient had a right hemothorax or a right
tension pneumothorax or perhaps cardiac tamponade since the path
of the knife was largely unknown.
Preparation of the patient's chest from neck to distal abdomen
was very rapidly prepped with Betadine. Using a scalpel an
incision was made in the 5th intercostal space on the right side
from mid axilla to sternum. This incision was carried down
through intercostal space into the right pleura. Upon entering
right pleura, a small amount of blood was noted, but there was
no evidence of a gross right hemothorax
or a right tension pneumothorax. The patient continued to be in
cardiopulmonary arrest and therefore the incision was carried
across the midline into the left and a formal clamshell
thoracotomy was performed involving both the right and left
hemithoraces.
The chest wall was elevated and quickly both hemithoraces
quickly examined. There was no evidence of hemothorax on the
right or the left side. The pericardium was quickly opened and
opened cardiac massage was performed. There was no evidence of
hemopericardium or cardiac tamponade. The patient responded with
reasonable blood pressure tracings upon open cardiac massage.
While there was no spontaneous electrical activity noted, nor
was there spontaneous cardiac contraction noted. The open
cardiac massage and full code was performed for an additional 15
minutes. Multiple ampules of epinephrine, bicarbonate, calcium
and atropine were administered, none of which resulted in
resumption of a cardiac rhythm or adequate perfusion. At 7:35
p.m. the code was called and the operation was terminated.
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 2762, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4647
} | Medical Text: Admission Date: [**2192-10-14**] Discharge Date: [**2192-11-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall at the nursing home
Major Surgical or Invasive Procedure:
Placement of right A-line
Placement of left Internal Jugular central line
History of Present Illness:
[**Age over 90 **] yo female, resident at [**Hospital 100**] Rehab with h/o dementia, PE and
DVT in [**5-20**] for which she has been on coumadin (INR 4.7 on
admission), CHF who was found on the floor at [**Hospital 100**] Rehab. Head
CT showed small right temporal intraparenchymal hemorrhage, 2x2
cm., which was unchanged on repeat head CT. INR was 4.7 and
platelets of 93 at the time of presentation. C-spine was cleared
by CT. In the ED, the patient was evaluated by NS and Trauma and
was felt not to be a candidate for intervention. She was
intubated for airway protection. Prior to being transferred to
MICU, the patient was loaded with Dilantin 1 gm IV once, INR
reversed with Vitamin K 10 units SC, 4units of FFP, 6 pack of
platelets. She was given Lasix 40 IV and received 1L NS for
hypernatremia.
Past Medical History:
1. osteoporosis
2. diverticulosis and h/o lower GI bleed secondary to
diverticulitis requiring subtotal colectomy
3. SSS s/p PPM
4. urosepsis
5. dry eyes
6. mild AI
7. CHF EF 20-30%
8. dementia
9. anxiety
10. hypercalcemia (?primary hyperparathyroidism)
11. blindness
12. anxiety
Social History:
Lives at [**Hospital 100**] Rehab. Rest of Social history is unknown. Son
[**Name (NI) **] is HCP. [**Telephone/Fax (1) 60538**]
Family History:
non-contributory.
Physical Exam:
afebrile HR 97 BP 116/71 RR 15 86% on vent (puls ox [**Location (un) 1131**] is
not reliable)
AC 400 x 16; PEEP 5; FiO2 100%
GEN: thin elderly lady, intubated and sedated
HEENT: large left fontal hematoma; eyes with clouded cornea;
small pupils; no obvious reaction to light
NECK: supple no LAD
CV: tachy, irreg irreg, no m/r/g
LUNG: crackles b/l bases
ABD: + BS, soft, nt, midline scar, LLQ hematoma
EXT: 2+ edema b/l ext
NEURO: unable to assess as patient is intubated/sedated
Rectal: guaiac + per ED note
Pertinent Results:
Admission Labs:
.
[**2192-10-14**] 11:45AM PT-25.3* PTT-35.0 INR(PT)-4.7
[**2192-10-14**] 11:45AM PLT SMR-LOW PLT COUNT-93* LPLT-2+
[**2192-10-14**] 11:45AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+
[**2192-10-14**] 11:45AM NEUTS-67.2 LYMPHS-26.8 MONOS-4.0 EOS-1.6
BASOS-0.3
[**2192-10-14**] 11:45AM WBC-7.0 RBC-4.79 HGB-13.0 HCT-43.9 MCV-92
MCH-27.2 MCHC-29.7* RDW-18.9*
[**2192-10-14**] 12:13PM GLUCOSE-124* NA+-157* K+-7.4* CL--114*
[**2192-10-14**] 02:45PM CALCIUM-11.7* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2192-10-14**] 02:45PM GLUCOSE-129* UREA N-38* CREAT-0.8 SODIUM-157*
POTASSIUM-4.4 CHLORIDE-121* TOTAL CO2-26 ANION GAP-14
[**2192-10-14**] 05:00PM PT-17.0* PTT-112.9* INR(PT)-2.0
[**2192-10-14**] 05:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+
[**2192-10-14**] 05:00PM NEUTS-61.6 LYMPHS-33.5 MONOS-2.8 EOS-1.5
BASOS-0.6
[**2192-10-14**] 05:00PM WBC-5.5 RBC-3.56*# HGB-10.0* HCT-33.7*#
MCV-95 MCH-28.2 MCHC-29.8* RDW-19.3*
[**2192-10-14**] 05:00PM CALCIUM-11.9* PHOSPHATE-2.3* MAGNESIUM-2.3
[**2192-10-14**] 05:00PM GLUCOSE-196* UREA N-36* CREAT-0.9 SODIUM-158*
POTASSIUM-4.5 CHLORIDE-116* TOTAL CO2-25 ANION GAP-22*
[**2192-10-14**] 05:17PM LACTATE-5.0*
[**2192-10-14**] 05:17PM TYPE-[**Last Name (un) **] TEMP-36.7 RATES-/18 PO2-19* PCO2-51*
PH-7.38 TOTAL CO2-31* BASE XS-2 INTUBATED-INTUBATED
[**2192-10-14**] 07:07PM LACTATE-2.8*
[**2192-10-14**] 07:07PM TYPE-ART PO2-423* PCO2-31* PH-7.60* TOTAL
CO2-32* BASE XS-9 INTUBATED-INTUBATED
[**2192-10-14**] 10:34PM URINE MUCOUS-MOD
[**2192-10-14**] 10:34PM URINE HYALINE-10*
[**2192-10-14**] 10:34PM URINE RBC-115* WBC-11* BACTERIA-MANY
YEAST-NONE EPI-4
[**2192-10-14**] 10:34PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-TR
[**2192-10-14**] 10:34PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.020
[**2192-10-14**] 10:34PM PT-14.8* PTT-29.5 INR(PT)-1.5
[**2192-10-14**] 10:34PM PLT COUNT-96*
[**2192-10-14**] 10:34PM WBC-5.9 RBC-3.81* HGB-10.4* HCT-34.3* MCV-90
MCH-27.3 MCHC-30.2* RDW-18.9*
[**2192-10-14**] 10:34PM CALCIUM-11.5* PHOSPHATE-1.5* MAGNESIUM-2.1
[**2192-10-14**] 10:34PM CK-MB-3 cTropnT-0.02*
[**2192-10-14**] 10:34PM CK(CPK)-70
[**2192-10-14**] 10:34PM GLUCOSE-123* UREA N-36* CREAT-0.8 SODIUM-158*
POTASSIUM-3.3 CHLORIDE-118* TOTAL CO2-31 ANION GAP-12
Pertinent Labs/Studies:
.
[**2192-10-14**] 10:34PM BLOOD CK-MB-3 cTropnT-0.02*
[**2192-10-15**] 06:07AM BLOOD CK-MB-NotDone cTropnT-0.03*
.
Imaging:
[**2192-10-14**]: CT Head: IMPRESSION: Temporal intracerebral
hemorrhage and subcutaneous hematoma in the left frontal region.
.
[**2192-10-15**]: CT Head: IMPRESSION: Stable appearance of right
temporal intraparenchymal hemorrhage.
.
[**2192-10-19**]: Portable Chest: IMPRESSION: Congestive heart failure
with slight improvement in degree of pulmonary edema.
.
[**2192-11-1**]: Portable Chest: Portable supine AP radiograph of the
chest is reviewed, and compared with the previous study of
[**2192-10-29**]. There is marked increase in severe pulmonary
edema probably due to congestive heart failure associated with
cardiomegaly and bilateral pleural effusion. There is increased
atelectasis in both lower lobes. The possibility of
superimposed pneumonia cannot be excluded. Pacemaker leads and
nasogastric tube remain in place. No pneumothorax is
identified. The radiograph is suboptimal in technique.
.
.
Microbiology:
Blood cultures:
[**10-18**]: No growth to date
[**10-19**]: No growth to date
Urine:
[**10-15**]: 2 colonies, both E. Coli, pan-sensitive
[**2192-10-25**]: Yeast > 100K CFU
Stool:
[**10-14**]: Cultures negative
C. Diff negative x 4
.
Sputum:
[**10-15**]: > 25pmns, < 10epi. Gram Positive cocci in pairs and
clusters
- moderate growth of MRSA
Discharge Labs: Patient deceased [**2192-11-2**]
.
[**2192-11-1**] 03:46AM BLOOD WBC-6.9 RBC-2.95* Hgb-8.3* Hct-26.7*
MCV-91 MCH-28.2 MCHC-31.2 RDW-20.1* Plt Ct-210
[**2192-11-1**] 03:46AM BLOOD Glucose-144* UreaN-21* Creat-0.5 Na-143
K-3.8 Cl-102 HCO3-34* AnGap-11
[**2192-11-1**] 03:46AM BLOOD Calcium-10.8* Phos-2.0* Mg-1.7
[**2192-10-21**] 03:41AM BLOOD calTIBC-194* Ferritn-174* TRF-149*
[**2192-10-30**] 07:09AM BLOOD Type-ART pO2-96 pCO2-48* pH-7.37
calHCO3-29 Base XS-1
Brief Hospital Course:
A [**Age over 90 **] year-old female with a history of dementia, CHF, DVT and PE
([**5-20**]), Afib, previously on anticoagulation therapy admitted
s/p fall with intraparenchymal hemorrhage on admission.
.
#. Right Temporal Lobe Cerebral Hemorrhage: The patient was
transferred to [**Hospital1 18**] s/p fall at [**Hospital 100**] Rehab. Patient was found
to have a 2x2 intraparenchymal bleed on CT with noted decline in
mental status while in the ED. This bleed occurred in the
setting of a supertherapautic INR from coumadin. The patient had
immediate reversal of her anticoagulation with 4 units of FFP
and received 6 units of platelets for thrombocytopenia with
platelet count of 93 and was loaded on dilantin for seizure
prophylaxis and started on Keppra as well. The patient was
evaluated by neurosurgery who did not feel there was an
indication for surgery, but did recommend reversal of
anticoagulation with goal of INR < 1.3 and platelets > 1000. The
patient was transferred to the ICU and intubated for airway
protection. The patient had a sodium of 158 on admission and was
given NS for hypovolemia followed by free water repletion to a
normal sodium which was discontinued after normalization and
also upon recommendation from neurosurg given concern for
increasing edema in setting of intracranial bleed. With regards
to her bleed, the patient had two repeat Head CTs which
demonstrated stable bleed without expansion or midline shift.
Given that the hematoma was stable, neurosurgery signed off
recommending repeat Head CT in approximately 4 weeks time. Upon
further discussion, they reported to the treating team that the
patient's prognosis with regards to her mental status changes
would be expected that she should return to her previous
baseline prior to this accident. However, the treating team and
geriatrics team following the patient felt that given her
baseline mental status and the multiorgan damage ensuing from
this accident, that it was probable the patient would not fully
recover from this accident. Given her stable lesion and no
evidence of ongoing bleed, patient's platelet transfusion
threshold lowered to 50K in attempt to decrease fluids as
patient has been developing body volume overload and anasarca in
setting of volume resuscitation for hypotension. The patient
demonstrated very slow to no improvement in neurologic status.
She demonstrated some increasing amounts of spontaneous
movements and was able to open eyes to commands, but performed
very few other commands. When not stimulated, despite being off
all sedatives, the patient remained relatively obtunded. The
patient was maintained on Dilantin and Keppra. After detailed
discussion re: prognosis and potential for recovery with [**Name (NI) 1094**]
son [**Doctor First Name **], HCP), the [**Name (NI) 1094**] code status was changed to
DNR/DNI/CMO, and the Pt. passed away comfortably from
cardiorespiratory arrest/failure shortly after.
.
#. Hypotension: Upon transfer to the MICU the patient had been
requiring volume support and pressors to maintain a MAP > 60. On
admission patient was initially receiving fluid boluses and
started on levophed for hypotension and decreased urine output.
Given the patient was developing total body fluid overload,
including moderate to severe pulmonary edema, levophed was
increased in an attempt to limit fluid support, with goal of
fluid boluses for CVP < 14. In setting of increased levophed the
patient's blood pressure did indeed respond, but she also
developed rapid ventricular response to her Afib. Therefore,
levophed was weaned and the patient was switched to
neosynephrine for pressure support. The patient's CVP goals were
additionally decreased with fluid boluses for CVP < 8, again
given worsening fluid overload. The etiology of the patient's
hypotension is unclear, but likely related to her poor cardiac
function and possibly infection, although the patient never
developed a leukocytosis or fever. The patient had a sputum
culture with moderate growth of MRSA and a urine culture growing
E. Coli (see ID) for which the patient has been treated. Over
the course of time, the patient has been weaned off
neosynephrine and has been maintaining a MAP > 60 without any
fluid or pressor support. She had been diuresed with a net
negative fluid balance of 500 to 1000cc each day and was
tolerating diuresis well without any associated hypotension.
.
#. Respiratory: The patient was initially intubated for airway
protection in the setting of intraparenchymal hemorrhage, with
propofol sedation. The patient was initially placed on AC with
blood gases revealing adequate oxygentation without hypercarbia.
She was switched to pressure support 15/5, with blood gases that
indicated again appropriate ventilation and oxygenation, but the
patient was noted to have intermittent episodes of apnea. The
patient was therefore changed to MMV setting on the vent, again
noted still to trigger vent-initiated breaths for periods of
apnea. On physical exam, the patient was additionally noted
periodically to have periods of rapid ventilation alternating
with periods of apnea, concerning for dysregulation of centrally
mediated respiratory drive. Throughout the hospital course this
respiratory pattern seemed to resolve and the patient had a more
regular pattern of breathing. Of note however, the patient
occasionally had periods of apnea. In attempt to help avoid
respiratory suppression, the patient was started on diamox and
potassium chloride to reduce metabolic alkalosis as an
inhibitory respiratory signal. The patient had a RSBI of 109
with intentions to continue to attempt to wean the patient from
ventilatory support. As above, the patient was noted during her
hospital course to have suctioned sputum with moderate growth of
MRSA. Although unclear if this growth represented pure
colonization, tracheobronchitis or true vent assoicated
pneumonia, the patient was initiated on vancomycin therapy in
attempt to correct any reversible cause constributing to ongoing
respiratory distress and inability to wean from the ventilator.
The patient additionally suffered from moderate to severe CHF
with pulmonary edema and effusions. The patient had been
undergoing successful diuresis with net negative 1500cc over
last 72 hours although over the course of her admission she
still remains 15L positive.
.
#. Afib - The patient had a DDD pacer that was placed for an
indication of sick sinus syndrome. Cardiology consult was
requested as the pacer was noted to be inappropriately firing
despite ventricular beats on admission. The patient's rhythm on
admission and throughout her stay had been Afib. Indeed,
interrogation of the pacer revealed that her atrial lead
detected properly and revealed Afib. Her ventricular lead
detected native ventricular beats as well. However it was found
that the sensitivity of the lead was too low and was adjusted so
that the ventricular lead would not inappropriately fire any
longer. With inappropriate firing the patient was at risk for Q
on T and subsequent V-fib, but her pacing dysfunction likely was
thought to have no relationship to her fall as it would not
cause a bradycardia or asystole. Given the patient's bleed, all
anticoagulation was held. As above, her anticoagulation was
reversed. The patient has known Afib as well as known DVT and
PE previously placing her again for increased risk of clot and
embolus, but necessarily so given her bleed. The patient's
metoprolol has additionally been held given her hypotension. The
patient was noted to have RVR in setting of levophed drip, but
since discontinuing, had ventricular reponse rate in the 80-110
range not requiring any further intervention.
.
#. CHF EF 20-30% - On admission, patient known to have CHF with
reported ejection fraction of 20-30%. The patient required
holding her metoprolol and lisinopril as above given her
persistent hypotension and additionally required large amounts
of fluid bolusing. The patient's obligate fluid load during her
MICU admission had resulted in moderate to severe pulmonary
edema. This degree of edema may have additionally been limiting
patient's ability to wean from vent. Initially, effective
diuresis was limited by the patient's persistent hypotension.
However, since resolution of her hypotension, the patient has
been diuresing well to very small doses of lasix, 10 to 20mg a
day with net negative fluid balance of 500cc to 1000cc per day.
.
#. ID: Since admission, the patient was afebrile without
leukocytosis. The patient had sputum cultures from [**2192-10-15**] with
moderate growth of MRSA. Although the patient had not had fever
or leukocytosis or radiographic evidence of pneumonia, therapy
was initiated with vancomycin in an attempt to treat any
reversible causes underlying patient's ongoing clinical picture
including hypotension and failure to wean form vent. Urine
cultures from [**2192-10-15**] were additionally found to be growing >
100K E. Coli (pan-sensitive) as well as GPC, likely alpha strep
or lactobacillus. The patient was initially started on Zosyn
when only gram negative rods were known, which has since been
changed to Bactrim given pan-sensitive E. Coli. The patient
completed a 7 day course for this infection. All blood cultures
since admission demonstrated no growth.
.
#. Recent PE and DVT - As above all anticoagulation was held
given recent intracranial bleed.
.
#. Hypercalcemia: Patient's hypercalcemia was thought to be
chronic and likely secondary to primary hyperparathyroidism as
she has an elevated PTH in setting of mild hypercalcemia.
Patient's hypercalcemia was stable throughout the hospital
course, not requiring any additional treatment.
.
#. Dementia: Patient has baseline dementia, by report at
baseline she was able to interact and communicate. Patient's
Donepezil and all other non-essential medications were held
during her MICU course in setting of altered mental status and
hypotension with need to minimize all but essential meds.
.
#. FEN: Patient was started on tube feeds for nutrition after
intubation.
Medications on Admission:
Tylenol
MVI
Tobramycin/Dexamethasone OP 1 appl qhs to right eye
Coumadin
Artificial tears
Aspirin 81 mg po daily
Bacitracin/Polymixin 1 appl [**Hospital1 **] to left eye
Calcium/Vit D 500 mg po tid
Cyanocobolamine 259 mcg po daily
Cyclosporine 1 ggt [**Hospital1 **] to right eye
Donepezil 10 mg po daily
Furosemide 20 mg po daily
Lisinopril 5 mg po daily
Metoprolol 50 mg po bid
Discharge Medications:
not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial Hemorrhage.
Respiratory failure.
Discharge Condition:
Expired.
Discharge Instructions:
not applicable.
Followup Instructions:
not applicable.
Completed by:[**2192-12-5**]
ICD9 Codes: 4280, 4240, 2760, 2875, 5990, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4648
} | Medical Text: Admission Date: [**2141-4-4**] Discharge Date: [**2141-4-6**]
Date of Birth: [**2118-11-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 22 y.o male with PMH of DM1 with prior episodes of DKA,
he is unable to quantify how many,who presented to the ED today
with N/V and was found to be in DKA after missing "some insulin"
doses. Pt reports that he has been dealing with epigastric
abdominal pain for days/n/v. PT not very specific to details of
further questions. However, he denies
f/c/sob/cp/dysuria/headache/LH
In the [**Name (NI) **] pt was started on an insulin gtt.
Past Medical History:
-DM type 1 dx [**2130**]
DKA [**2138-5-6**] after a night of drinking and and missing insulin
doses, multiple admits per report of DKA/N/V
-?gastroparesis, reportedly normal gastric emptying study
-depression
-HTN
-hypothyroidism
-esophageal tear
Social History:
PT lives at home with his parents and reports that he does a
"minimum wage job". Smokes [**11-30**] ppd, denies ETOH or drug use.
Family History:
Non-contributory
Physical Exam:
vitals: T 98.6 BP 107/56 HR 68 RR 19 sat 98% on RA
HEENT: nc/at, perrla, eomi, anicteric, very poor dentition
neck: no LAD
chest: b/l ae no w/c/r
heart: s1s2 rrr no m/r/g
abd: +bs, mild epigastric TTP, soft, no guarding, no rebound
ext: no c/c/e 2+pulses
neuro: non-focal
Brief Hospital Course:
The patient is a 22 y.o male with DM1 who presents with
abdominal pain/n/v after missing insulin doses and found to be
in DKA.
DKA: The patient presented to the ER after missed "a few" lantus
doses. He was found to he in DKA. He received 2L IVF's and
started on an insulin gtt. Admitted to the ICU and was
maintained on an insulin drip and IVF's. Anion gap closed and
the patient was transitioned to SQ insulin. He was transferred
to the medical floor. He was restarted on his home doses of
insulin. His sugars were well controlled and he was discharged
home with plans to follow up at [**Last Name (un) **] next week.
Medications on Admission:
Humalog
Lantus
Reglan 5mg before meals
Levothyroxine Sodium 25mcg 1 time per day
Maalox Quick Dissolve 600mg as needed
Prilosec 20mg 1 time per day
Lisinopril 10mg 1 time per day
Lax Stool Softener 5 mg
Wellbutrin Sr 150mg twice a day
Phenergan 25mg as needed
Clonidine Hcl 0.2mg as needed
Humalog 100 U/ml twice a day
Senna 8.6mg twice a day
Desyrel 50mg
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
2. Insulin Lispro 100 unit/mL Solution Sig: 1-20 units
Subcutaneous four times a day: please use sliding scale to
determine doses.
3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for with meals.
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Desyrel 50 mg Tablet Sig: One (1) Tablet PO QHS.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
DKA
Secondary Diagnosis:
Hypertension
Type I DM
Depression
Discharge Condition:
Stable, tolerating PO's, sugars well controlled.
Discharge Instructions:
You were admitted to the hospital with DKA because of not taking
your insulin. Please take you insulin EVERY day. This is very
important. Please also make sure you follow up at [**Last Name (un) **] next
week.
We did not make any medication changes while you were here.
Please return to the ER for nausea, vomiting, chest pain, or
elevated blood sugar.
Followup Instructions:
You have an appointment with your primary care doctor, [**First Name11 (Name Pattern1) 31804**]
[**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7405**] on [**2141-5-3**] at 1:30pm.
Please make an appointment with [**Last Name (un) **] next week.
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4649
} | Medical Text: Admission Date: [**2139-8-1**] Discharge Date: [**2139-8-6**]
Date of Birth: [**2089-5-8**] Sex: M
Service: KIRLAND
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
gentleman with a history of schizo-affective disorder and
hyponatremia secondary to SIADH as well as psychogenic
polydipsia, history of hypertension, osteoarthritis, GERD,
and childhood asthma who presents on [**2139-8-1**] with a three
day history of shortness of breath and nonproductive cough as
well as increasing lower extremity edema. He went to his PCP
and was found to have a saturation of 58% on room air that
increased to 88% on nonrebreather. He was sent to the
Emergency Room. A chest x-ray was consistent with
interstitial bilateral pulmonary infiltrates as well as
edema. The patient received levo, Lasix, and was transferred
to the [**Hospital Unit Name 196**] Service for workup of hypoxia.
On the [**Hospital Unit Name 196**] Service, the patient was found to be increasingly
hypoxic with saturation of 88% which increased to 92% on
nonrebreather. He was transferred to the MICU Service. In
the MICU, the patient was felt to have a mixed CHF/community
acquired pneumonia picture. He was maintained on Lasix,
azithromycin, and ceftriaxone and was maintained on BIPAP.
The patient improved on BIPAP and on [**2139-8-5**] was transferred
to the Medicine Service for further management.
While in the unit, the patient had a CTA which was positive
for lymphadenopathy and diffuse small areas of consolidation
but negative for PE or dissection. A PTE was also performed
which revealed an ejection fraction of 55%, symmetric LVH,
left atrial enlargement, right atrial enlargement. The
patient was diuresed in the MICU and his shortness of breath
improved considerably. Additionally, his lower extremity
edema as well as cough also improved.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Schizo-affective disorder.
3. Osteoarthritis.
4. Lower extremity edema.
5. GERD.
6. SIADH.
7. Psychogenic polydipsia.
8. Hypothyroidism.
9. Childhood asthma.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Father died of MI at 40. Mother died of MI
at 68. Positive tobacco history. Extensive smoking for
multiple years. Currently smokes, although attempting to
stop. No ETOH. No other drugs. Married times 11 years.
HOSPITAL COURSE: 1. SHORTNESS OF BREATH: This was felt to
be due to a combination of CHF as well as community acquired
pneumonia. His EF and E/A ratio were consistent with
diastolic dysfunction. The patient also has lymphadenopathy
on CTA which needs to be followed up by his primary care
physician within [**Name Initial (PRE) **] few months with an x-ray or CT. While on
the Medicine Service, the patient was continued on Lasix at
40 mg q.d. to 40 mg IV b.i.d. for fluid overload. He had
very good response to this and diuresed nicely. Otherwise,
he was continued on azithromycin for a total of five days and
his ceftriaxone was discontinued. He was also maintained on
levofloxacin for better gram-negative coverage.
2. CONGESTIVE HEART FAILURE: The patient had strict I&Os,
daily weights, and Lasix p.r.n. He diuresed very nicely and
his oxygen saturations improved considerably on 2 liters.
The patient subjectively reported that he was feeling much
better with a decrease in cough as well as ease of breathing.
3. ELECTROLYTES: On admission, the patient's sodium was
found to be 111. He was maintained on a fluid restriction
and his sodium self-corrected and improved. By the date of
discharge, the sodium had corrected to 130. The patient
should be continued on a fluid restriction at 1,000 cc per
day. Otherwise, the patient had an elevated bicarbonate
which was felt to be consistent with contraction alkalosis
secondary to diuresis. Additionally, his creatinine was
followed and creatinine remained within a normal range of 0.4
to 0.7 and he was also maintained on a low-salt diet.
4. PSYCHIATRY: The patient was maintained on Risperdal as
well as divalproex and Lorazepam.
5. HYPERTENSION: The patient's blood pressures are well
controlled on metoprolol as well as Captopril. His
metoprolol was titrated up in an effort to afford better beta
blockade. Additionally, Lipids were checked and were
elevated with LDL of 151, triglycerides 161, and HDL 24 with
a ratio of 8.6. Hence, a statin was initiated.
Additionally, an aspirin was added for cardioprotective
benefits.
6. ENDOCRINE: The patient's TSH was also checked and was
within normal limits. He was maintained on Synthroid.
7. PHYSICAL THERAPY: PT evaluate the patient and ambulated
with the patient. The patient continued to desaturate on
ambulation to the 80s. Hence, it was felt that the patient
should be placed at pulmonary rehabilitation for further
rehabilitation for his pulmonary status. The patient was a
full code.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure.
2. Community acquired pneumonia.
3. Hypertension.
4. Schizo-affective disorder.
5. Osteoarthritis.
6. Lower extremity edema.
7. Gastroesophageal reflux disease.
8. Syndrome of inappropriate antidiuretic hormone.
9. Psychogenic polydipsia.
10. Hypothyroidism.
11. Childhood asthma.
DISCHARGE MEDICATIONS:
1. Menthol lozenges one p.o. q. six hours p.r.n.
2. Risperidone 2 mg p.o. q.a.m., 2.5 mg one p.o. q.h.s.
3. Divalproex 500 mg one p.o. q.i.d.
4. Pantoprazole 40 mg one p.o. q.d.
5. Lorazepam 1 mg p.o. q.i.d.
6. Levothyroxine 250 mcg one p.o. q.d.
7. Metoprolol 25 mg one p.o. b.i.d.
8. Captopril 12.5 mg one p.o. t.i.d.
9. Enteric coated aspirin one p.o. q.d.
10. Lasix 60 mg one p.o. q.d.
11. Levofloxacin 500 mg one p.o. q.d. times five days.
12. Lipitor 10 mg one p.o. q.d.
CONDITION ON DISCHARGE: Fair to stable.
FOLLOW-UP: The patient is to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 1144**] on [**2139-8-17**] at 10:45 a.m. This is the patient's
primary care physician. [**Name10 (NameIs) **] this visit, the patient's
electrolytes should be checked given that the patient is on
Lasix and has a history of hyponatremia secondary to SIADH
and psychogenic polydipsia. Additionally, his potassium and
creatinine should be checked to assess for hypokalemia as
well as overdiuresis. Furthermore, the patient's
lymphadenopathy on CTA should be followed up with periodic
chest x-ray/CTs.
DISPOSITION: The patient will currently be discharged to a
rehabilitation center for pulmonary rehabilitation. He will
likely have a five to ten day stay, at which time he will be
discharged to home and needs to follow-up with his primary
care physician as indicated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2139-8-6**] 11:44
T: [**2139-8-6**] 12:01
JOB#: [**Job Number 14803**]
ICD9 Codes: 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4650
} | Medical Text: Admission Date: [**2137-7-6**] Discharge Date: [**2137-7-16**]
Date of Birth: [**2137-7-6**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname 11674**] [**Last Name (NamePattern1) 56427**] is a former
1.835 kg product of a 33-6/7 week gestation pregnancy born to
a 32-year-old G1, P0 woman. Prenatal screens: Blood type A-
negative, antibody positive, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group B Strep status
unknown. The pregnancy was complicated by pregnancy-induced
hypertension. The mother was given betamethasone two weeks
prior to delivery. She was followed for spontaneous fetal
heart rate decelerations and mild oligohydramnios.
On the day of birth, she was taken to emergent C section for
a nonreassuring fetal heart rate tracing and that the fetus
was in breech position. The infant emerged vigorous with
good cry. Apgars were eight at one minute and eight at five
minutes. He was given blow-by oxygen. He was admitted to
the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.835 kg, 25th percentile; length 44 cm,
25-50th percentile; head circumference 30 cm, 25th
percentile. General: Nondysmorphic preterm male, mildly
tachypneic. Skin: No rashes or petechiae. Head, eyes,
ears, nose, and throat: Anterior fontanel flat. Red reflex
present bilaterally. Palate intact. Chest: Clear breath
sounds with few inspiratory crackles. Cardiovascular: Normal
S1, S2. No murmur. Pulses plus 2 and equal. Abdomen is
soft, no hepatosplenomegaly, no masses. GU: Normal male.
Testes descended bilaterally. Anus patent. Spine intact.
Extremities: Hips stable. Reflexes and neurological:
Moving all extremities. Normal tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname 11674**] remained in room air from admission
to the Neonatal Intensive Care Unit. The tachypnea noted
upon admission resolved over the first few hours after
birth. He has had no episodes of spontaneous apnea. At
the time of discharge, he is breathing comfortably with a
respiratory rate of 30-50. Oxygen saturations on room air
have been greater than or equal to 95 percent.
2. Cardiovascular: [**Known lastname 11674**] has maintained normal heart rates
and blood pressures. Most recent blood pressure was 73/40
with a mean of 52. No murmurs have been noted.
3. Fluid, electrolytes, and nutrition: Enteral feeds were
started on day of birth and gradually advanced to full
volume. At the time of discharge, he is taking 150
cc/kg/day of mother's breast milk fortified to 24
calories/ounce with human milk fortifier. He takes his
feedings by gavage every four hours. He also goes to
breast with mother.
Initial serum glucoses on four hour feeds had lows below 50
prior to feeding, which resolved with the addition of the
extra calories. At the time of discharge, his weight is 1.79
kg. His low weight since birth was 1.735 kg on days [**4-18**] of
life.
4. Infectious disease: Due to the unknown group B Strep
status of the mother and his prematurity, [**Name (NI) 11674**] was
evaluated for sepsis. A white blood cell count was 10,400
with a differential of 40 percent polymorphonuclear cells,
1 percent band neutrophils. A blood culture was obtained
and was no growth at 48 hours. [**Known lastname 11674**] was not treated
with antibiotics.
5. Gastrointestinal: [**Known lastname 11674**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life three, a total of
9, direct of 0.3 for an indirect of 8.7 mg/dl. He
received approximately 48 hours of phototherapy. His
rebound bilirubin was total of 6.9, 0.3 direct, and 6.6
indirect on day of life five.
6. Hematological: Hematocrit at birth was 58.6 percent.
[**Known lastname 11674**] is blood type A negative with a direct Coombs test
negative. He did not receive any transfusions of blood
products during admission.
7. Neurological: [**Known lastname 11674**] has maintained a normal neurological
exam during admission and there were no concerns at the
time of discharge.
8. Sensory: Audiology: Hearing screening has not yet been
performed and is recommended prior to discharge.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 3765**] for
continued level II care. The primary pediatrician is Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 44696**], [**Hospital **] Medical Associates, [**Street Address(2) 56428**], [**Location (un) **], [**Numeric Identifier 56429**], phone number [**Telephone/Fax (1) 39136**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Feeding:
150 cc/kg/day of breast milk fortified to 24 calories/ounce
PG every four hours.
No medications.
Car seat position screening is recommended prior to discharge
per recommendation of the American Academy of Pediatrics.
State newborn screen was sent on [**2137-7-8**] and [**2137-7-16**] with
no notification of abnormal results to date.
No immunizations administered as yet.
Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of three of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-6/7 weeks gestation.
2. Suspicion for sepsis ruled out.
3. Transitional respiratory distress, resolved.
4. Unconjugated hyperbilirubinemia, resolved.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2137-7-12**] 01:11:03
T: [**2137-7-12**] 06:12:53
Job#: [**Job Number 56430**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4651
} | Medical Text: Admission Date: [**2169-5-4**] Discharge Date: [**2169-5-9**]
Date of Birth: [**2099-7-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Throat burning with exertion in cold weather
Major Surgical or Invasive Procedure:
-status post Off Pump Coronary Artery Bypass Grafting x2 (left
internal mammary artery->Diagnal/Saphenous vein graft ->distal
Left anterior descending artery)-[**2169-5-4**]
History of Present Illness:
69 yo male who during his routine physical mentioned to his PCP
that he had [**2-8**]
isloated episodes of throat burning associated with cold
weather,
stress and walking briskly. He also relates episodes of
epigastric burning which he thought was acid reflux. A stress
test was scheduled and during stage I patient developed [**Street Address(2) 2051**]
depression in II, III, AVF and ST elevation in AVR, AVL and V1.
He denies symptoms of throat burning or epigastric distress
during ETT. EKG changes resolved with rest and he was
transferred to [**Hospital1 18**] for cardiac cath. During cardiac
catheterization his LAD was dissected. He was taken to the OR
emergently.
Past Medical History:
Hypertension, Hyperlipidemia
Social History:
SOCIAL HISTORY: Retired lawyer, lives with wife. Social ETOH
and
no tobacco use. Does not exercise and does not follow a special
diet.
Family History:
No early family history of CAD
Physical Exam:
PHYSICAL EXAMINATION:
v/s: 98.4 - 84 - 12 - 188/102
Generally the patient was well developed, well nourished and
well
groomed. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate. Skin pink,
warm and dry.
There was no xanthalesma and conjunctiva were pink with no
pallor
or cyanosis of the oral mucosa. The neck was supple with JVP of
6 cm. There was no thyromegaly. The were no chest wall
deformities, scoliosis or kyphosis. The respirations were not
labored and there were no use of accessory muscles. The lungs
were clear to ascultation bilaterally with normal breath sounds
and no adventitial sounds or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. There were no femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed 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:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 83468**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83469**]
(Complete) Done [**2169-5-4**] at 7:30:25 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2099-7-11**]
Age (years): 69 M Hgt (in): 70
BP (mm Hg): 140/86 Wgt (lb): 220
HR (bpm): 68 BSA (m2): 2.18 m2
Indication: CAD, dissected LAD during cardiac cath. Intraop
management
ICD-9 Codes: 786.05, 786.51, 440.0
Test Information
Date/Time: [**2169-5-4**] at 19:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.3 cm
Left Ventricle - Fractional Shortening: *-0.43 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Pulmonary Artery Main Diameter: 2.3 cm < 3.0 cm
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA. Lipomatous hypertrophy of the interatrial
septum. Dynamic interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mildly thickened
mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
Patient is on a balloon pump.
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
5. The mitral valve leaflets are structurally normal. The mitral
valve leaflets are mildly thickened.
6. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
7. During off pump cabg the endocardium continued to move well
despite external compression
8. Dr. [**Last Name (STitle) **] was notified in person of the results
during surgery on [**2169-5-4**] at 1739.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
Brief Hospital Course:
On [**5-4**] Mr.[**Known lastname **] was taken emergently to the operating room
for LAD dissection and underwent Offpump Coronary Artery Bypass
Grafting x2 (left internal mammary artery grafted to the
Diagnal/Saphenous vein grafted to the distal Left Anterior
Descending artery)with Dr.[**Last Name (STitle) **]. Please refer to
Dr[**Doctor First Name **] operative report for further details. He was
intubated and sedated, critical but hemodynamically stable on
transfer to the CVICU. Intraoperatively the balloon pump was
removed from his left groin. Upon arrival to the CVICU his groin
began bleeding No changes in hemodynamics and no loss of distal
pulses occurred. Vascular team was consulted. An ultrasound of
the left groin was performed and revealed no pseudoaneurysm or
A-V fistula. He awoke neurologically intact and was extubated on
POD#1. All lines and drains were discontinued in a timely
fashion. Beta-blocker initiated. POD#2 Mr.[**Known lastname **] was
transferred to the step down unit for further progression and
monitoring. He continued to do well and was ready for discharge
to home with VNA on POD# four. All follow up appointments were
advised.
Medications on Admission:
Vasotec 10 mg daily, Simvastatin 40 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Toprol XL 100 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*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
-status post Off Pump Coronary Artery Bypass Grafting x2 (left
internal mammary artery->Diagnal/Saphenous vein graft ->distal
Left anterior descending artery)-[**2169-5-4**]
-Hypertension, Hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Name (NI) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr.[**Last Name (STitle) **],[**First Name3 (LF) 1575**] J. [**Telephone/Fax (1) 14655**] in 1-2weeks please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2169-5-9**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4652
} | Medical Text: Admission Date: [**2125-10-28**] Discharge Date: [**2125-11-2**]
Date of Birth: [**2070-10-3**] Sex: M
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Sudden onset of left-sided weakness and lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 724**] is a 55 year old with hx of CAD, CHF (EF 15% with
apical thrombus), h/o severe MR s/p St. Jude valve [**2123**] (on
Coumadin), HTN, DM, high cholesterol, who presented on [**10-28**]
with one day of left sided weakness and lightheadedness.
*
On the day prior to admission, he started to feel dizzy while
sitting down watching television. He tried to get up to go to
the bathroom. At that time, he noted left arm and leg weakness.
He had difficulty walking, but was able to take a shower. His
left side also felt numb. His wife and son helped him get ready
for bed. He went to sleep and woke up on the day of admission
with left-sided weakness. He then decided to come the ER.
*
In the ER, he was found to have BP 157/83 HR 73 RR18 O2Sat 99%.
Exam was significant for inattention to left side, righ gaze
deviation, right eye skew deviation, vertical upgaze palsy, left
hemiparesis, left hemisensory loss. CT Scan showed 4cm x 3cm
right basal ganglia/thalamic bleed with extension to right
lateral ventricle with mass effect and slight midline shift.
There was also extension inferiorly into the midbrain. His INR
was found to be 2.7. He was given 2400U Factor VII and 2U FFP to
reverse coagulopathy. He was also given Vit K 10mg SC. He was
started on a labetalol drip to keep MAP less than 100. He was
admitted to the NICU.
Past Medical History:
1. CAD: s/p MI [**2115**], s/p CABG [**2116**], s/p PTCA [**2119**] with stent
placement
2. Ischemic cardiomyopathy and CHF. Echo in [**2119**] with EF 15%,
apical thrombus, s/p AICD
3. s/p MV replacement with St. Jude valve for severe MR, [**2123**] by
Dr. [**Last Name (STitle) 1537**]
4. Hypertension
5. Hypercholesterolemia
6. Diabetes
7. Gout
8. Chronic renal insufficiency, bsln Cr ~2
9. s/p AICD
10. Hyperparathyroidism s/p parathyroidectomy [**2122**]
11. Gallstones
Social History:
Lives with wife and son. [**Name (NI) **] is a bartender and lives in [**Location 577**].
He is a former smoker-quit 30yrs ago, no EtOH or drugs.
Physical Exam:
Mental status: Slightly lethargic, but arousable, cooperative
with exam. Oriented to person, place, and time. Attentive, says
[**Doctor Last Name 1841**] backwards (made 2 mistakes). Speech is fluent with normal
comprehension and repetition; naming intact. Mild dysarthria.
[**Location (un) **] intact. Registers [**3-7**], recalls [**2-6**]. Able to perform
basic calculations. No evidence of apraxia. Is inattentive to
left side.
*
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields intact. On neutral gaxe, eyes are
deviated to the right with skew deviation of right eye.
Bilateral sixth nerve palsy. Bilateral upgaze palsy. Sensation
decreased V1-V3 on left. Left UMN facial. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid [**5-9**] on right. Trapezius [**2-8**] on left. Tongue
midline without fasciculations, intact movements
*
Motor:
Normal bulk bilaterally. Tone increased on the left. No
adventitious movements. Left arm and leg are plegic. Right arm
and leg with full strenght throughout.
*
Sensation:
Intact to light touch, pinprick and vibration and proprioception
on right. Left hemisensory loss to all modalities.
*
Reflexes:
B T Br Pa Ach
Right 2 2 2 2 2
Left 2 2 2 2 2
*
Grasp reflex absent
*
Toes were downgoing on right, upgoing on left.
*
Coordination:
normal on finger-nose-finger and heel to shin on right-unable to
assess on left.
Pertinent Results:
[**2125-11-2**] 10:00AM BLOOD WBC-10.6 RBC-4.23* Hgb-12.7* Hct-37.2*
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.6 Plt Ct-255
[**2125-11-1**] 05:00AM BLOOD WBC-11.4* RBC-3.88* Hgb-11.8* Hct-34.5*
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.7 Plt Ct-195
[**2125-10-31**] 01:50AM BLOOD WBC-12.4* RBC-4.04* Hgb-12.1* Hct-35.6*
MCV-88 MCH-29.8 MCHC-33.9 RDW-14.1 Plt Ct-175
[**2125-11-2**] 10:00AM BLOOD Plt Ct-255
[**2125-11-2**] 10:00AM BLOOD PT-13.2 PTT-25.0 INR(PT)-1.1
[**2125-11-2**] 10:00AM BLOOD Glucose-197* UreaN-31* Creat-1.5* Na-142
K-4.1 Cl-109* HCO3-22 AnGap-15
[**2125-10-29**] 07:50AM BLOOD cTropnT-0.04*
[**2125-10-28**] 11:35PM BLOOD CK-MB-5 cTropnT-0.04*
[**2125-10-28**] 06:00PM BLOOD CK-MB-4 cTropnT-0.02*
[**2125-10-28**] 11:35PM BLOOD %HbA1c-6.3*
[**2125-10-29**] 04:57AM BLOOD Triglyc-172* HDL-45 CHOL/HD-3.8
LDLcalc-93
Brief Hospital Course:
55 yo male with h/o HTN, St. [**Male First Name (un) 923**] mitral valve, ischemic
cadiomyopathy, DM, high cholesterol, CAD with right thalamic
bleed in context of anticoagulation with coumadin. His exam is
significant for left sided inattention, upgaze palsy, bilateral
sixth nerve palsy, skew deviation of right eye, left hemiplegia,
and left hemisensory loss. All of these findings are c/w right
thalamic bleed, and the bilateral 6th nerve palsy may be
explained by intracranial hypertension.
*
1. Neuro: ICH likely due to HTN complicated by anticoagulation
(INR 2.7).
- While in the ICU, the patient was started on Mannitol 25mg IV
q4h, which was d/c'ed on [**10-31**] on transfer to the floor.
- The patient was first on a nicardipine drip and then on a
labetalol drip for BP control, for target MAP < 110 and goal SBP
< 140. BPs remained fairly well controlled on drip, but he had
episodes of agitation where BP was increased to 190's. On [**10-31**],
he was transitioned to po metoprolol (as below).
- Repeat head CTs on [**10-29**] and [**10-30**] showed stable appearance of
the bleed.
- The patient's exam remained unchanged during his
hospitalization.
*
2. Cardiac:
- HTN - On [**2125-10-22**], metoprolol was increased to 75mg tid and
home losartan (50mg qd) restarted. Pt was continued on home dose
hydralazine (50mg [**Hospital1 **]).
- AICD in place
*
3. Heme: A/C reversed with Vit K, FFP and factor 7 in ER.
- Coumadin was d/c'ed, and the patient's goal INR was 1-1.5
throughout his hospital stay.
- Baby aspirin [**Name2 (NI) **] was started on [**2125-11-1**].
.
**** The decision was made that the patient should be restarted
on coumadin on [**2125-11-4**] (one week from the date of his event),
and that he should be started with low dose and advanced slowly.
Given the risk of bleed, it was felt that his goal INR should be
2.5-3. The risks and benefits of coumadin in the setting of
hemorrhagic stroke were discussed with the patient, his family,
and the patient's cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
*
4. Endo: DM
- Patient had been on sliding scale in NICU, and on transfer to
the floor on [**2125-10-21**] was placed on standing NPH as well as
humalog sliding scale. NPH doses were increased daily.
*
5. Pulm:
- The pt had a low grade temp on [**10-30**] and CXR was obtained to
r/o PNA. CXR was normal, but left lung base was not adequately
visualized. A PA and lateral showed no infiltrate. Sats were
good and pt did not have T spike.
*
6. F/E/N:
- Diabetic, cardiac diet
- Pt coughed during neuro exam with thin liquids. Videoswallow
showed that the patient had no difficulty with thin liquids, but
did have difficulty with mixed consistency liquids.
Recommendations were: 1. Thin liquids, soft solids. 2. Meds
whole in puree. 3. NO MIXED CONSISTENCIES (i.e., cold ceral with
milk, soup,
most fruit- bananas are okay). 4. No straws. Please encourage pt
to take single sips of liquid from the cup, versus continuous
"chug a lug" drinking.
*
7. Renal:
- CRI, likely secondary to diabetic nephropathy
- Creatinine stable while in hospital (d/c Cr 1.5)
*
8. Prophylaxis: Pneumoboots, H2 blocker, aspiration precautions
*
9. To [**Hospital1 **] for rehab.
.
Page 1 instructions:
1. ANTICOAGULATION. Please start anticoagulation with coumadin
on Sunday night, and check INR again at least by Wednesday
morning. Goal INR should be 2.5-3.0 in the setting of the
patient's resolving intracranial hemorrhage. INR needs to be
monitored very carefully in this patient. This issue has been
discussed with the patient's cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], and any
questions can be discussed with him. The patient has a follow-up
appointment with Dr. [**Last Name (STitle) **] on [**2125-11-15**].
.
2. HYPERTENSION. The patient was admitted on Toprol XL 150mg qd,
in addition to losartan and hydralazine. This regimen was
inadequate for the patient in the hospital, and Toprol XL was
d/c'ed, and metoprolol increased to 75 tid. As goal SBP is less
than 140 in the setting of intracranial hemorrhage, this patient
will need careful BP monitoring and titration of blood pressure
medications.
.
3. DIABETES. Begun on NPH 22U qAM and 17U qPM, with a qid
humalog sliding scale as attached.
.
4. PHYSICAL THERAPY
Medications on Admission:
Toprol XL 150
Glyburide/metformin 5/500 [**Hospital1 **]
Hydralazine 50 [**Hospital1 **]
Cozaar 50
Lipitor 80
Coumadin 5mg 5x/week and 2mg 2x/week (?)
KCl 20
Insulin ? dose
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
().
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
5. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Two (22) units Subcutaneous QAM.
8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventeen
(17) units Subcutaneous at bedtime.
9. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: As per
sliding scale units Subcutaneous four times a day: Humalog
sliding scale as attached, qid finger sticks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
- Right thalamic intracranial hemorrhage with intraventricular
extension
- HTN
- DM
- MVR ([**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**])
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER if you have any
further weakness or sensory loss, any difficulty breathing, or
any difficulty seeing, speaking, or swallowing.
*
Please take all your medications as directed.
Followup Instructions:
Appointment with cardiologist Dr. [**Last Name (STitle) **] on Thursday, [**11-15**] at 9am. [**Telephone/Fax (1) 5768**]. Location: [**Street Address(2) 24109**], [**Location (un) **], MA.
*
Please follow up in 1 month in stroke clinic at the [**Hospital1 **] [**First Name (Titles) 151**] [**Last Name (Titles) 850**] Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Call [**Telephone/Fax (1) 657**] to
set up an appointment.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4653
} | Medical Text: Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-10**]
Date of Birth: [**2151-1-20**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Sepsis.
Major Surgical or Invasive Procedure:
Central Venous Line Placement.
History of Present Illness:
Mr. [**Known lastname 37404**] is a 32 year-old man with no significant past
medical history who presents with sepsis.
The patient was in his usual state of health until the day of
admission when he began feeling nauseous with vomiting [**3-22**]
times. He also reports a mild headache (all over) and fevers
(none recorded) and rigors. Also with total body aches for
which he has been using tylenol. He visited [**Country 3400**] in
[**Month (only) **], then the [**Country 13622**] Republic in [**Month (only) 404**]. Otherwise no
recent travel.
ROS:
(-) Weight change
(+) Night sweats; chronic for many years
(-) Neck stiffness
(-) Abdominal pain, diarrhea, constipation
In reviewing OMR, there are repeated visits to [**Company 191**] with
diagnosis of viral pharyngitis. His most recent presentation
was in [**2182-11-16**] at which time he had complaints of "sore
throat" which was thought to be of viral origin. He then
presented to [**Company 191**] on [**2182-12-20**] with continued sore throat, along
with left-sided tonsil pain. Per the OMR note, the exam at that
time showed "Oropharynx with large edematous tonsils, left
greater than right, but only slightly erythematous. No
exudate." He was treated empirically with Azithromycin. He
feels that the Azithro helped somewhat.
In the ED, initial vitals showed a T of 101.2, HR 125, BP
109/62, RR 16 and 100%. When his blood pressure fell to 84/49
he was bolused with IVF and a sepsis line was placed. Up to 4
liters of NS were given, along wiht CTX, levaquin and Tamiflu.
Past Medical History:
1. Palpatations with accesory pathway
2. Low back pain
3. Tonsillitis three to four times per year as a child
4. GERD
Social History:
He is an immigrant of Moroccan extraction. He currently owns
his own limousine company. He is married, has a 2-year-old son.
His son, his wife, and his father all lives in his home. He is
a former cigarette smoker, he smoked approximately less than a
pack a day. He would over drink one to two alcoholic beverages
per week, and he has had none in over 4 years.
Family History:
Father with diabetes mellitus.
Physical Exam:
Vitals - T 102.0, BP 143/70, HR 114, RR 18, 100%.
GEN - Overweight man, lying in bed. Ill-appearing, but not
toxic.
HEENT - OP shows left sided tonsil with crypts. Some erythema.
No obvious exudate. No cervical, submandibular LAD. RIJ in
place. Neck is supple. Dry MM.
CV - Tachycardic. No murmurs.
PULM - Clear. No wheeze/rales/rhonchi
ABD - Soft. Non-tender. Non-distended.
EXT - Warm. No edema.
SKIN - Warm to hot. Birthmark on right abdominal wall. No
rash.
NEURO - Alert and oriented. Non-focal.
Pertinent Results:
Lactate: 4.3 --> 2.3 --> 1.7
.
1.004 / 7.0
.
138 99 14
------------ 118
4.4 24 1.3
.
WBC: 18.7
PLT: 267
HCT: 42.2
N:90.9 Band:0 L:6.1 M:2.6 E:0.1 Bas:0.3
.
ABD US ([**2183-3-6**]): 1. Increased liver echogenicity is mostly
consistent with the fatty liver, however, other liver disease
and more advanced liver disease including cirrhosis/fibrosis
cannot be excluded.
2. Normal gallbladder with no evidence of cholecystitis or
cholelithiasis.
.
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CT NECK W/CONTRAST (EG:PAROTIDS) [**2183-3-7**] 12:09 AM
FINDINGS: No abscess or fluid collection is noted within the
neck. Multiple pathologically enlarged nodes are noted in the
jugulodigastric regions bilaterally. For example, the large node
in the right jugulodigastric area measures 2.3 x 1 cm. The one
on the left side measures 1.6 x 1.3 cm. The nodes noted in other
stations of the neck are not pathologically enlarged. Mucosal
thickening of both maxillary sinuses is noted.
IMPRESSION: No abscess or fluid collection in the neck.
.
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2183-3-8**] 2:54 AM
COMPARISON: [**2183-3-7**].
As compared to the previous radiograph, there is no relevant
change. Known right-sided aortic arch. Central venous access
line in place. Normal size of the cardiac silhouette, no pleural
effusion.
.
.
.
.
.
.
.
.
.
.
................................................................
[**2183-3-10**] 04:55AM BLOOD WBC-8.3 RBC-5.55 Hgb-14.8 Hct-43.3
MCV-78* MCH-26.8* MCHC-34.3 RDW-12.8 Plt Ct-325
[**2183-3-9**] 04:02AM BLOOD WBC-9.2 RBC-5.18 Hgb-13.8* Hct-41.2
MCV-80* MCH-26.7* MCHC-33.6 RDW-12.5 Plt Ct-239
[**2183-3-8**] 04:27AM BLOOD WBC-16.3* RBC-4.39* Hgb-12.0* Hct-34.3*
MCV-78* MCH-27.3 MCHC-34.9 RDW-12.7 Plt Ct-196
[**2183-3-7**] 12:55AM BLOOD WBC-20.3* RBC-4.74 Hgb-12.8* Hct-36.6*
MCV-77* MCH-26.9* MCHC-34.9 RDW-12.1 Plt Ct-229
[**2183-3-6**] 06:35PM BLOOD WBC-18.7*# RBC-5.43 Hgb-14.9 Hct-42.2
MCV-78* MCH-27.4 MCHC-35.2* RDW-12.2 Plt Ct-267
[**2183-3-10**] 04:55AM BLOOD Neuts-51.4 Lymphs-39.5 Monos-5.6 Eos-2.2
Baso-1.4
[**2183-3-9**] 04:02AM BLOOD Neuts-63.8 Lymphs-29.3 Monos-5.2 Eos-1.1
Baso-0.6
[**2183-3-6**] 06:35PM BLOOD Neuts-90.9* Bands-0 Lymphs-6.1* Monos-2.6
Eos-0.1 Baso-0.3
[**2183-3-10**] 04:55AM BLOOD Plt Ct-325
[**2183-3-9**] 04:02AM BLOOD Plt Ct-239
[**2183-3-8**] 04:27AM BLOOD Plt Ct-196
[**2183-3-8**] 04:27AM BLOOD PT-14.7* PTT-27.0 INR(PT)-1.3*
[**2183-3-7**] 12:55AM BLOOD Plt Ct-229
[**2183-3-7**] 12:55AM BLOOD PT-15.1* PTT-27.9 INR(PT)-1.3*
[**2183-3-6**] 06:35PM BLOOD Plt Smr-NORMAL Plt Ct-267
[**2183-3-7**] 12:55AM BLOOD ESR-4
[**2183-3-10**] 04:55AM BLOOD Glucose-111* UreaN-18 Creat-1.1 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
[**2183-3-9**] 04:02AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-140
K-4.1 Cl-102 HCO3-28 AnGap-14
[**2183-3-8**] 06:16PM BLOOD Glucose-111* UreaN-9 Creat-0.9 Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2183-3-8**] 04:27AM BLOOD Glucose-128* UreaN-9 Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-26 AnGap-13
[**2183-3-7**] 12:55AM BLOOD Glucose-147* UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-108 HCO3-21* AnGap-15
[**2183-3-6**] 06:35PM BLOOD Glucose-118* UreaN-14 Creat-1.3* Na-138
K-4.4 Cl-99 HCO3-24 AnGap-19
[**2183-3-7**] 12:55AM BLOOD ALT-38 AST-28 LD(LDH)-132 CK(CPK)-75
AlkPhos-70 Amylase-66 TotBili-0.7
[**2183-3-7**] 12:55AM BLOOD Lipase-20
[**2183-3-7**] 12:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2183-3-10**] 04:55AM BLOOD Calcium-10.0 Phos-5.4* Mg-2.0
[**2183-3-9**] 04:02AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.9
[**2183-3-8**] 06:16PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
[**2183-3-8**] 04:27AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.7
[**2183-3-7**] 12:55AM BLOOD Albumin-3.9 Calcium-8.5 Phos-1.8* Mg-1.3*
[**2183-3-7**] 10:27AM BLOOD Cortsol-35.9*
[**2183-3-7**] 10:27AM BLOOD Cortsol-32.1*
[**2183-3-7**] 12:55AM BLOOD Cortsol-43.2*
[**2183-3-7**] 12:55AM BLOOD IgG-816 IgA-128 IgM-24*
[**2183-3-9**] 04:02AM BLOOD C3-169 C4-37
[**2183-3-6**] 11:17PM BLOOD Lactate-2.0
[**2183-3-6**] 10:17PM BLOOD Lactate-1.7
[**2183-3-6**] 07:58PM BLOOD Lactate-2.3*
[**2183-3-6**] 06:50PM BLOOD Lactate-4.3*
Brief Hospital Course:
ASSESSMENT/PLAN:
32 man with no past medical history who presents with septic
shock.
.
# Sepsis / Septic shock: Presents with leukoctyosis,
tachycardia and hypotension along with evidence of end-organ
injury (acute renal failure) and mild lactic acidosis. There is
no clear source of infection, though the oropharynx appears a
possible source; CT neck did not show any drainable collection
or abscess. Central line was placed and he received IV fluids
and brief pressor support. Cortisol testing demonstrated an
intact adrenal axis. His ICU course was complicated by an
episode of wide complex tachycardia which was felt to likely
represent atrial tachycardia with bypass tract. ID consultation
was obtained. Although the etiology of his sepsis-like syndrome
was initially unclear despite extensive evaluation, he was
treated empirically with broad-spectrum antibiotics for possible
bacterial source. Laboratory testing failed to confirm a
specific viral pathogen; HIV antibody and HIV viral load tests
returned negative, and influenza testing also returned negative
as well. He improved clinically. Throat culture from [**2183-3-7**]
eventually returned positive for sparse growth of Group A
beta-hemolytic strep. He was discharged on [**3-10**] with a
presumptive diagnosis of GABHS pharyngitis complicated by
sepsis, with instructions to continue antibiotics and follow up
with Dr [**Last Name (STitle) **] in [**Company 191**]. He was also discharged with a
prescription for acyclovir in the setting of newly-developed
herpes labialis.
Medications on Admission:
1. Multivitamin
2. Prilosec 20mg daily
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) for 4 days.
Disp:*22 Capsule(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*48 Capsule(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
strep pharyngitis
shock
Secondary:
GERD
WPW
recurrant pharyngitis
Discharge Condition:
good
Discharge Instructions:
You were admitted and treated for your low blood pressure and
presumed infection. You have had many tests sent - some are
still not resulted yet. You also have gotten antibiotics - some
of which you will need to continue for the next several days.
You are much improved and ready for discharge.
You will need to take all medications as instructed.
You have been started on three antibiotics: levaquin,
clindamycin, and acyclovir -> you need to continue taking these.
Please continue all of your home medications.
You will need to keep all of your follow-up appointments as
scheduled.
You need to call your doctor or return to the ED if T>101.5,
chills, nausea, vomiting, rash, or any other concern.
Followup Instructions:
You have a follow-up appointment scheduled on [**2183-3-20**] at
10:20am with Dr.[**Name (NI) 20819**] nurse practitioner. It is very
important that you keep this appointment. Please call to
confirm [**Telephone/Fax (1) 250**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**0-0-0**]
ICD9 Codes: 0389, 5849, 4271, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4654
} | Medical Text: Unit No: [**Numeric Identifier 75323**]
Admission Date: [**2161-11-23**]
Discharge Date: [**2161-12-15**]
Date of Birth: [**2161-11-23**]
Sex: M
Service: Neonatology
***POST DISCHARGE NAME: Burns, [**Known lastname 75324**]***
HISTORY OF PRESENT ILLNESS: [**Known lastname 75324**] is an ex-33 and [**12-28**]
week baby boy, [**Name2 (NI) **] by induced vaginal delivery, to a 35 year-
old, G2, P0 now 1 mother. She was induced secondary to
pregnancy induced hypertension. The infant's birth weight
was [**2183**] grams.
Maternal history and pregnancy was otherwise unremarkable
until at 33 weeks, she developed hypertension. Prenatal
screens: Blood type B positive, antibody negative, RPR
nonreactive, hepatitis surface antigen negative, Rubella
immune and GBS unknown.
At delivery, the infant emerged vigorous with spontaneous
cry. Routine resuscitation was administered. Apgars were 8
and 9. He was admitted to the NICU for management of
prematurity.
HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant has
remained on room air since birth. He has not had any
significant apneas, bradycardias or desats. Intermittently,
he has had some brief episodes of bradycardia that are self-
resolving. He was thus on a spell count just prior to
discharge. He has not required any caffeine administration.
Cardiovascular: The infant has remained hemodynamically
stable not requiring any pressor support. No murmur was ever
appreciated and therefore, work-up and treatment for PDA was
not necessary.
Fluids, electrolytes and nutrition: The infant initially was
on IV fluids and started enteral feeds on day of life 2. He
quickly worked up to full volume via pg feeds and presently
is now taking breast milk 24 k-cals per ounce ad lib by mouth
and takes approximately 130 cc/kg/day along with breast
feeding.
Hematology: The infant had elevated bilirubin on day of life
3 requiring phototherapy. Phototherapy was discontinued on
day of life 6 without subsequent increases. The infant has
not required any blood transfusions.
Infectious disease: Given that there were no maternal risk
factors present and the infant was well-appearing, the infant
was not started on any antibiotics and has not required any
courses in the stay in the Neonatal Intensive Care Unit.
Neurology: Since he is greater than 32 weeks, the infant did
not require head ultrasound.
Sensory:
Audiology: Hearing screening was performed with automated
auditory brain stem responses. He passed the screening
bilaterally.
Ophthalmology: The infant was greater than 32 weeks. He did
not require an eye examination.
DISCHARGE DISPOSITION: The infant will be discharged to
home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10817**] of [**Hospital 620**]
Pediatrics, [**Telephone/Fax (1) 37814**]. Fax [**Telephone/Fax (1) 47970**].
DISCHARGE PHYSICAL EXAM: On the day of discharge, [**12-15**],
the infant weighed 2630 grams which is at the 50th percentile.
The length was 44 cm, between the 25th and 50th percentile.
Head circumference 31cm, just at the 25th percentile. On
examination, general appearances: The infant is active and
vigorous, moving all extremities. Head and neck: Anterior
fontanel is open and flat. Red reflexes are intact
bilaterally. The infant's palate is intact. Pulmonary: Clear
to auscultation bilaterally. CV: S1 and S2, regular rate
and rhythm. No murmur appreciated. Abdomen is soft,
nondistended, no masses. Extremities: Warm and well
perfused. Plus 2 femoral pulses. Genitourinary: Normal
male genitalia. Testes are descended bilaterally.
Circumcision site is healing. Anus is patent. There is a small
sacral dimple. Neuro: Positive suck, positive Moro, appropriate
for gestational age.
CARE AND RECOMMENDATIONS: Feeds at discharge: The infant is
being discharged home on breast milk, 24 k-cals per ounce.
Medications: The infant is taking iron at 2 mg/kg per day as
well as Goldline multi-vitamins 1 ml by mouth daily.
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 i.u.
(may be provided as a multi-vitamin preparation) daily until
12 months corrected age.
Car seat position screening was successfully performed.
State newborn screening was performed and results are
pending.
IMMUNIZATIONS RECEIVED: The infant received hepatitis B
vaccine on [**2161-12-4**].
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) [**Month (only) **] at less than 32
weeks; (2) [**Month (only) **] between 32 weeks 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; (3) chronic lung disease or (4)
hemodynamically significant congenital 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.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOW-UP APPOINTMENTS: The infant will be seeing the
primary pediatric provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10817**] of [**Hospital 620**]
Pediatrics on Wednesday, [**12-15**] at 10am.
VNA services will also be visiting the infant shortly after
discharge.
DISCHARGE DIAGNOSIS: Prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 75325**]
MEDQUIST36
D: [**2161-12-11**] 08:38:09
T: [**2161-12-11**] 09:14:21
Job#: [**Job Number 75326**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4655
} | Medical Text: Admission Date: [**2169-6-26**] Discharge Date: [**2169-7-5**]
Date of Birth: [**2108-4-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CP/SOB worsening
Major Surgical or Invasive Procedure:
AVR(19mm CE Perimount) [**2169-6-26**]
History of Present Illness:
61 y/o female w/ c/o intermittent c/p. Along with SOB. On Echo
found to have severe AS.
Past Medical History:
Aortic stenosis
Hypertension
Hypercholesterolemia
Asthma
Gastroesophageal Reflux Disease
s/p r. Total Hip Replacement 99
s/p Tonsillectomy
Social History:
Unknown
Family History:
Non-contributory
Physical Exam:
VS: 75 131/64 5'2" 200#
General: Obese female in NAD
Heart: RRR 3/6 SEM with radiation to carotids
Lungs CTAB -w/r/r
Abd: Obese, NT/ND +BS
Ext: -c/c/e
Neuro: CN 2-12 intact, MAE, non-focal
Pertinent Results:
[**2169-6-27**] 01:57AM BLOOD WBC-14.6* RBC-3.08* Hgb-9.9* Hct-29.2*
MCV-95 MCH-32.1* MCHC-33.9 RDW-14.6 Plt Ct-158
[**2169-7-5**] 06:58AM BLOOD WBC-10.3 RBC-3.69* Hgb-11.8* Hct-35.5*
MCV-96 MCH-32.0 MCHC-33.3 RDW-15.2 Plt Ct-334#
[**2169-6-26**] 03:33PM BLOOD PT-18.5* PTT-40* INR(PT)-2.3
[**2169-6-26**] 04:35PM BLOOD PT-16.1* PTT-33.3 INR(PT)-1.7
[**2169-6-29**] 02:18AM BLOOD PT-13.3 PTT-29.0 INR(PT)-1.2
[**2169-6-26**] 04:35PM BLOOD UreaN-5* Creat-0.5 Cl-112* HCO3-22
[**2169-6-27**] 01:57AM BLOOD Glucose-104 UreaN-7 Creat-0.7 Na-139
K-5.0 Cl-108 HCO3-21* AnGap-15
[**2169-7-5**] 06:58AM BLOOD Glucose-101 UreaN-7 Creat-0.6 Na-139
K-4.5 Cl-104 HCO3-24 AnGap-16
[**2169-7-3**] 06:55AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.2
[**2169-6-28**] 09:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2169-6-28**] 09:12AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.034
Brief Hospital Course:
As mentioned in the HPI, this is a 61 y/o female with a h/o
severe AS who was originally seen as an outpt. who was a same
day admit and brought to the OR on admit day. In OR she
underwent an AVR with a total bypass time of 102 and cross-clamp
time of 80. Please see op note for full surgical details. She
tolerated the procedure well and was transferred to CSRU with a
MAP 79, CVP 16, PAD 20, [**Doctor First Name 1052**] 26, HR 88 and being titrated on Neo,
Propofol, and Amio. She remained extubated throughout the night.
In addition to above gtts, Milrinone and Insulin were started.
TTE was performed on POD #1 which was nl. Diuretics started this
day. Pt. was slowly weaned from mechanical ventilation and on
POD #2 she was extubated. She was awake, alert, MAE, and
following commands. Natrecor was started today and Milrinone and
neo were weaned off. B-blockers were started after neo was
weaned. She remained in the CSRU until POD#4 on a Natrecor gtt
and was transferred to telemetry floor on POD #4. Pt. had rales
bilat. with a CXR showing bilat. effusion and LLL atelectasis.
Swan-Ganz catheter and chest tubes were removed per protocol.
Pt. had RAF overnight into POD #5. Amio was restarted. K was
repleted. Pacing wires were removed. On POD #6 pt was having
diarrhea and a c.diff culture was sent which came back negative.
Flagyl was started in the interrum which gave pt. relief. Lasix
was held until K was repleted. Pt. slowly improved through POD
#[**8-12**]. She was ambulating well and getting OOB. Her labs were
stable. Exam was pretty unremarkable and she was d/c'd on POD
#9.
Medications on Admission:
1. Lipitor
2. Norvasc
3. Zantac
4. Albuterol
5. [**Doctor First Name **]
6. ASA
7. Tylenol
8. MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fexofenadine HCl 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-5**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 5 days: Then decrease to 400 mg PO daily for 1
week, then decrease to 200 mg PO daily.
Disp:*60 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Hypertension
Hypercholesterolemia
Asthma
Gastroesophageal Reflux Disease
s/p r. Total Hip Replacement 99
s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructons.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Do not put any creams or lotions on wounds.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 9751**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2169-7-6**]
ICD9 Codes: 4241, 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4656
} | Medical Text: Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-13**]
Date of Birth: [**2120-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Chief Complaint: LLE pain and SOB
Reason for MICU transfer: close hemodynamic monitoring
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 70 yo M with a hx of PE/DVT [**8-23**] whose
anticoagulation was recently stopped [**3-30**] after a neg CTA and
negative doppler study, who now presents with recurrent DVT/PE.
He reports experiencing left sided lower extremity edema that
has been present since his initial DVT presentation [**8-23**]. This
became significantly work for the past 2 days, along with left
foot pain. He presented to [**Hospital3 **], where he was
found to have an extensive DVT in the LLE and was given a dose
of lovenox 100 mg at 0220 and coumadin 10 mg at 0200. He also
reportedly endorsed some discomfort and a CTA revealed a saddle
PE. He was subsequently transferred to [**Hospital1 18**] for further
management. Pt reports he is only minimally ambulatory due to
"pinched nerves in the spine" that have been active for the past
2.5 years. He has been even less active more recently, given
that he experiences LLE radicular pain and SOB with any
ambulation after about one minute. He does feel his SOB was
particularly worse this past friday and believes his blood clots
are related to his lack of ambulation.
In the ED, initial VS were: 97.6 57 188/77 16 99% 2L Nasal
Cannula. Reportedly a bedside u/s showed no right heart strain.
ECG showed did not show RHS, but did show old inferior and
possible anterior infacts. Labs were notable for a proBNP of 565
and a negative trop.
On arrival to the MICU, the patient states he feels
uncomfortable, but this is due to his chronic radicular pain.
He denies feeling chest discomfort, SOB, palpitations or
dizziness.
Review of systems:
Per HPI, also reports recent bout of diarrhea about 1 month ago,
resolved with stopping PO Mg, metformin and starting immodium.
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies coughor wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation, abdominal pain, dark or
bloody stools. He does report recent bleeding hemorrhoids that
occurred in setting of [**Last Name (un) **] prep last week. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-CAD s/p CABG x3 in [**2171**]
-Diabetes mellitus
-Hx DVT/PE [**8-23**]
-Hx nephrolithiasis
-Gout
-Hx MI [**2170**]
-Hypercholesterolemia
-Morbid obesity
-HTN
-Hx of chronic radicular pain x 2.5 years, radiating from left
knee to hip. Has received several epidural steroid injections,
most recently 2-3 weeks ago.
-umbilical hernia
-Hx bladder Ca 4-6 years ago - dx with hematuria, cystoscopy
showed a lesion that was resected. This was localized, no known
recurrence.
-Hx prostate Ca 5 years ago s/p resection and xrt, localized,
followed with PSAs.
-Hx tonsillectomy
-Rotator cuff injury [**2-21**], currently undergoing PT
-Hx colonic polyps - last colonoscopy [**4-23**], 1 polyp removed
Social History:
Married, lives with wife. [**Name (NI) **] grown children who live in the
area. Retired, used to work as a technical writer. Denies
tobacco, Etoh, illicit drugs.
Family History:
Father, brother and several uncles with [**Name2 (NI) 499**] cancer. Mother
with breast cancer. Sister died of a stroke about 1 month ago.
No known history of blood clots or miscarriages.
Physical Exam:
Admission Physical Exam:
Vitals: HR 59, BP 151/77, RR 16, 100% on RA
General: Alert, oriented, no acute distress. Obese middle aged
male.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not appreciably elevated, although difficult
to assess given body habitus
CV: Distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-distended, bowel sounds present, no
tenderness to palpation
Ext: Warm, well perfused, 1+ pulses pulses b/l. [**12-13**]+ pitting
edema in LE b/l, L > R
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
[**2191-5-9**] 07:00AM BLOOD WBC-5.8# RBC-3.98* Hgb-12.7* Hct-38.2*
MCV-96 MCH-31.8 MCHC-33.2 RDW-13.9 Plt Ct-221
[**2191-5-9**] 07:00AM BLOOD Neuts-67.5 Lymphs-20.9 Monos-6.9 Eos-4.1*
Baso-0.6
[**2191-5-9**] 07:00AM BLOOD PT-12.1 PTT-65.5* INR(PT)-1.1
[**2191-5-9**] 07:00AM BLOOD Glucose-136* UreaN-18 Creat-1.2 Na-136
K-4.5 Cl-98 HCO3-28 AnGap-15
[**2191-5-9**] 07:00AM BLOOD cTropnT-<0.01
[**2191-5-9**] 07:00AM BLOOD proBNP-565*
.
OSH US: + DVT in LLE
.
OSH CTPA:
saddle pulmonary emboli extending bilaterally subsegmental and
segmental without acute CT heart strain or consolidations.
2. Active small airway disease int he bases.
3. Cholelithiasis without cholecystitis or pancreatitis.
.
[**2191-5-11**] ECHO:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). 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 root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate mitral regurgitation.
Brief Hospital Course:
Patient is a 70 yo M with Hx of DVT/PE who recently completed a
course of anticoagulation and now presents with extensive LE DVT
and saddle PE.
.
ACTIVE ISSUES:
.
# PE/DVT - The patient has a history of PE/DVT which was treated
for approximately 7 months and had discontinued treatment in
[**Month (only) 547**]. The patient is up to date on cancer screening with a
recent colonoscopy (with a reported polyp seen -path pending),
normal PSA. He does have a hx of prostate and bladder cancer.
He is relatively immobile. There is no family history of blood
clots or other bleeding disorders. He was transferred from
[**Hospital3 2783**] to the ICU at [**Hospital1 18**] for close hemodynamic
monitoring. The patient did not have any SOB at rest but did
endorse some DOE that was worse recently. He was treated with a
heparin gtt and bridged to coumadin. Hematology was consulted
regarding the need for further hypocoagulable work up and a
question of the need for an IVC filter. They did not feel
either was necessary but recommended that he have a bridge to
coumadin for 48 hrs and that he remain on coumadin life long.
The pt was not bridged with lovenox given his weight was> 100kg.
A TTE was obtained which did not show evidence of RV strain.
it was a limited study due to his obesity but showed no major
structural abnormalities with only mild LVH. The patient never
required oxygen. He was able to ambulate the hallways without
significant difficulty prior to discharge. His foot pain that
he had at admission resolved.
.
#HTN - his antihypertensives were held at admission. Metoprolol
and HCTZ were restarted and during his hospitalization and as he
remained hypertensives to the 140-170s, Avapro was restarted at
discharge as well.
.
# DM - Byetta and glimepramide were held during his
hospitalization and restarted on discharge. He was continued on
Lantus qhs and a humalog SS.
.
# CAD s/p CABG - continued ASA, pravastatin, BB.
.
# HL - continued pravastatin
.
# Radicular pain - chronic, continued on quinine.
.
TRANSITIONS OF CARE:
Mr. [**Known lastname 5607**] will follow up at the [**Hospital 2436**] [**Hospital **]. He has historically required low doses of coumadin
approximately 11.25 mg/week.
Medications on Admission:
Medications: confirmed with wife
aspirin 81 mg daily
Avapro 300 mg daily (irbesartan)
hydrochlorothiazide 25 mg daily
metoprolol tartrate 50 mg 1 in morning, [**12-13**] in evening
pravastatin 40 mg daily
glimepiride 4 mg daily
Byetta 10 mcg/0.04 mL per dose Sub-Q [**Hospital1 **] before meals
Levemir 100 unit/mL Sub-Q 20 units at bedtime
Qualaquin 324 mg Cap Oral 1 qhs
potassium 99 mg Tab daily
omeprazole 20 mg daily
immodium [**12-13**] tab Daily - takes prn
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. quinine sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
7. Coumadin 2.5 mg Tablet Sig: half tablet (1.25 mg) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1)
Subcutaneous with meals.
12. Levemir 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous at bedtime.
13. Imodium A-D 2 mg Tablet Sig: [**12-13**] tab Tablet PO once a day as
needed for diarrhea, loose stools.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. potassium 99 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PE
DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for leg pain and found to have a recurrent DVT
and pulmonary embolus. You were started on a heparin drip and
transitioned to coumadin with a 48 hour overlap. Given the size
of the blood clot, you were evaluated by hematology who
recommended that you continue on coumadin life long.
New meds: coumadin
Followup Instructions:
Follow up in the coumadin clinic on [**Last Name (LF) 766**], [**5-16**], at 11AM.
Follow up with your PCP as scheduled. Their clinic will call
you with an earlier appointment if they are able to see you
sooner.
ICD9 Codes: 2749, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4657
} | Medical Text: Admission Date: [**2124-7-31**] Discharge Date: [**2124-8-5**]
Date of Birth: [**2065-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cath- [**7-31**]
CABG- [**8-1**]
History of Present Illness:
Patient is a 59yo male with multiple cardiac risk factors
presenting with chest pain during cath procedure today. Balloon
pump placed and pain resolved. Currently is asymptomatic and
stable.
.
He reports recent worsening of this "chest sensation" in the
last month. Said in the last week, he has used his nitro
4-5x/day. Up until one month ago, he "never" used his nitro.
Reports some additional anxiety since he got the stress test
results back and thinks that is contributing to his increased
use of nitro. Denies having any chest pressure, just this
sensation which is described as follows: starts with a tightened
sensation in his throat that progresses down to his heart. Does
not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in
the cath lab today and when he got to the CCU. At this time, he
is not having any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
.
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. Hhe denies recent fevers, chills or
rigors. He reports denies exertional buttock and calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain
at present, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3. OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
Social History:
He is currently laid off, but he used to work inmodification of
vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics. Intentionally lost 30
pounds and 3 inches of his waist line over the past three years.
He follows a low-fat diet.
Family History:
His mother died at age 85. His father is 88 with heart disease
and lung cancer. Father had a CABG in his 70s
Physical Exam:
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. difficult to auscultate given balloon pump
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: Slightly cool to palpation. Right cooler than left
Pulses dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) 2325**]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Pertinent Results:
[**2124-7-31**] 02:15PM BLOOD %HbA1c-5.3
[**2124-7-31**] 02:15PM BLOOD Triglyc-162* HDL-69 CHOL/HD-3.1
LDLcalc-111
CARDIAC CATH: [**2124-7-31**]
LAD: ostial 95%. Heavy Calcium mid vessel 95%, distal 50%, D1
and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals
from LAD filling the distal vessel. LPLV has proximal 20%
stenosis.
RCA: Total occlusion with collaterals from LCA.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82902**] (Complete)
Done [**2124-8-1**] at 9:09:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-2-23**]
Age (years): 59 M Hgt (in): 66
BP (mm Hg): / Wgt (lb): 190
HR (bpm): BSA (m2): 1.96 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 440.0, 410.92
Test Information
Date/Time: [**2124-8-1**] at 09:09 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Moderately
dilated LV cavity. Moderate regional LV systolic dysfunction.
Moderately depressed LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with mid-distal anterior, anteroseptal and
apical severe hypokinesis/akinesis. No apical thrombus is seen.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35%%). The right ventricle displays
borderline normal free wall function. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion. An intra-aortic balloon (IAB) is seen with
its tip at the level of the distal aortic arch/proximal
descending aortic transition area. Dr. [**Last Name (STitle) 914**] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. The focal
abnormalities of the apical, anterior, and anteropseptal walls
noted in the pre-bypass study are improved and now display mild
hypokinesis. The left ventricular systolic function is now in
the 40 to 45% range. Valvular function is unchanged. The
thoracic aorta appears intact. The IAB remains as noted in the
pre-bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2124-8-1**] 13:39
Brief Hospital Course:
Angina- Patient experienced angina while undergoing cath
procedure on [**7-31**]. Cath showed 3VD. Intra-aortic balloon
placed to improved coronary flow. Upon admission to floor,
nitro gtt was restarted. Heparin IV as well as IABP heparin
protocol started. He had residual pain that resolved upon
resuming nitro gtt. EKG initially showed isolated STE in V2
with T-wave inversion in avL and V3. Enzymes trended. Denied
any chest pain overnight. Was seen and evaluated by CT [**Doctor First Name **].
Mr. [**Known lastname 2816**] was taken to the OR for CABG x4 (LIMA-LAD, SVG-diag,
SVG-OM, SVG-PDA)on [**8-1**]. IABP was removed post-opeeratively.
Immediately after surgery Mr. [**Known lastname 2816**] was admitted to the CVICU
intubated, sedated and on epi and levo. Mr. [**Known lastname 2816**] was
extubated on POD#1 and epi and levo were weaned off. Chest tubes
were removed and Mr. [**Known lastname 2816**] was transferred to the floor on
POD#2. He was started on diuresis, betablockade and stain
therapy. Pacing wires were removed on POD#3. He was evaluated by
physical therapy and cleared for d/c home on POD#4.
Medications on Admission:
simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl
.4/prn,
[**Last Name (LF) 82903**], [**First Name3 (LF) **] 81', Paxil 40'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. [**First Name3 (LF) 82903**] Oral
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
dyslipidemia
peripheral vascular disease depression
hypertension
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] 1 week
Dr. [**Last Name (STitle) **] [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Sternal Precautions
No lifting greater than 10 pounds for 10 weeks
No driving for 1 month and off narcotics
Cardipulmonary Assessment
Wound Care
Medication Compliance
Follow up appointment compliance
[**Hospital1 **] INSTRUCTIONS:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) **] 3 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name (STitle) **],THEVERTHUDIYIL K. [**Telephone/Fax (1) 82904**] in 1 week
Dr. [**Last Name (STitle) 911**] in [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2124-8-5**]
ICD9 Codes: 2761, 2762, 412, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4658
} | Medical Text: Admission Date: [**2112-3-4**] Discharge Date: [**2112-3-16**]
Date of Birth: [**2045-7-26**] Sex: F
Service: ICU
CHIEF COMPLAINT: Change in mental status, leukocytosis and
abdominal pain.
HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
white female with a history of biliary colic, status post
ERCP and cholecystectomy, possible cholangiocarcinoma,
hypertension, and [**Hospital **] transferred to the Intensive Care Unit
status post an emergent ERCP.
The patient developed biliary colic approximately one year
ago and was found to have gallstones and a common bile duct
stone, for which she underwent ERCP with papillotomy and
subsequently a cholecystectomy. In the interim, the patient
also underwent an umbilical hernia repair.
In [**2111-11-27**], the patient developed recurrent
abdominal pain, the workup for on an abdominal CT revealed a
left hepatic lobe abnormality with ductal dilatation
concerning for cholangiocarcinoma. The patient underwent
ERCP at an outside hospital on [**2112-2-18**], which showed
intrahepatic and common bile duct stricturing. Cholangiogram
at that time revealed common bile duct strictures as well.
Brushings sent for cytology were positive for atypical cells
suspicious for adenocarcinoma.
The patient was admitted to [**Hospital 6138**] Hospital with
increasing abdominal pain on [**2112-2-28**] with a total
bilirubin of 4.6, alkaline phosphatase 751, and a white blood
cell count of 10.5 which later increased to 15.9. The
patient's pain was somewhat controlled with MS Contin and
Oxycontin IR, but this was complicated by altered mental
status. The patient developed a sinus tachycardia on
[**2112-3-2**] with report of anterolateral ST changes on
EKG and positive troponin by report.
The patient was transferred to the Intensive Care Unit and
began on a beta blocker. Because of confusion, increasing
white blood cell count, the patient was begun on Tequin and
gentamicin for empiric coverage for cholangitis. The patient
was transported for emergent ERCP. The patient was given
ceftriaxone 1 gram and vancomycin 1 gram prior to ERCP at the
[**Hospital1 69**].
At ERCP, intrahepatic ductal stricturing and common bile duct
stricturing were noted for which the patient received common
bile duct stents times two. Because of the severe pain and
altered mental status, the patient was electively intubated
for the procedure and a right internal jugular central venous
line was placed.
PAST MEDICAL HISTORY:
1. Biliary colic and common bile duct stone, as per history
of the present illness.
2. Status post umbilical hernia repair.
3. CVA.
4. Hypertension.
5. Cholangiocarcinoma, questionable.
6. Hypercholesterolemia.
7. By report, prior echocardiograms with normal ejection
fraction. No valvular disease.
ALLERGIES: The patient is allergic to sulfa and penicillin.
ADMISSION MEDICATIONS:
1. Gemfibrozil.
2. Verapamil.
3. Aspirin.
4. Lipitor.
5. Triamterene.
6. Percocet.
FAMILY HISTORY: The patient's mother died of a myocardial
infarction in her 60s.
SOCIAL HISTORY: The patient does not use alcohol. There is
a report of past tobacco use, but she quit several years ago.
The patient was physically active until her recent illness.
She lived with her husband.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
current 97.5, blood pressure 101/88, heart rate 108,
respiratory rate 12, oxygen saturation 100% on room air.
General: She was an intubated, sedated, jaundiced female in
no acute distress. Cardiovascular: Regular rate and rhythm
without murmurs, gallops, or rubs. Lungs: Clear to
auscultation bilaterally. Right anterior basilar crackles.
Abdomen: Soft and nontender with moderate to severe
distention. No masses. Negative bowel sounds. Extremities:
Calves soft, nontender, without edema. Neurological:
Intubated, sedated.
LABORATORY DATA: White blood cell count 16.1, hematocrit
31.1, platelets 672,000. INR 1.4. PTT 23. Sodium 135,
potassium 4.7, chloride 99, bicarbonate 23, BUN 17,
creatinine 0.5, glucose 81. Alkaline phosphatase 811, total
bilirubin 7.7, AST 67, amylase 15, lipase 2, albumin 2.7,
calcium 9.0, phosphorus 3.7, magnesium 2.0. CK 44, lactate
1.4.
Her preintubation ABG revealed a pH of 7.4, PC02 35, P02 73,
bicarbonate 25.
Abdominal CT from an outside study on [**2112-3-2**]
revealed ductal dilation extending from the porta hepatis to
intraductal areas. There was a small amount of
intraperitoneal fluid. Distal, transverse, and descending
colon with localized ileus, right peripheral consolidation
with effusion.
The EKG on [**2112-3-2**] revealed sinus tachycardia at
128, normal axis, intervals, T wave inversions in V3 through
V6, I, III, and aVF without prior EKGs for comparison.
The chest x-ray revealed bilateral hilar congestion. No
cephalization. Bilateral interstitial infiltrates with a
focal right lower lobe infiltrate with effusion.
HOSPITAL COURSE: 1. PULMONARY: The patient was electively
intubated prior to her procedure. She remained on minimal
ventilatory support on low pressor support settings. Because
of her altered mental state, she continued to be mechanically
ventilated until care was later withdrawn (see below).
2. CARDIOVASCULAR: Throughout her stay, the patient
remained hemodynamically stable. The patient did have a
troponin leak consistent with a non-ST segment myocardial
infarction with a peak troponin I of about 6.0. Given the
absence of ST depressions or elevations in the EKGs from the
outside hospital or [**Hospital6 256**],
this was felt to be highly unlikely to be a primary cardiac
event, rather a demand-related myocardial infarction.
3. GASTROINTESTINAL/HEPATOBILIARY: The patient's ERCP was
very concerning for cholangiocarcinoma given the diffuse
stricturing. The patient underwent an abdominal CT. An
abdominal CT was performed on [**2112-3-6**] which revealed
bilateral pleural effusions with compressive atelectasis, a
large amount of free fluid in the abdomen and pelvis, intact
common bile duct stents, bilateral renal stones. There was
liver contrast-enhancement consistent with cholangiocarcinoma
and multiple mesenteric lymph nodes.
Given the probable metastatic cholangiocarcinoma, the patient
was evaluated by General Surgery and the Biliary Service and
felt to have a very dismal overall prognosis for treatment or
recovery. The patient's total bilirubin and alkaline
phosphatase then gradually trended down.
4. INFECTIOUS DISEASE: The patient remained afebrile
throughout her stay. She was empirically covered on
vancomycin, Levaquin, and Flagyl for empiric coverage of
cholangitis.
5. COMMUNICATION/DISPOSITION: Given the patient's overall
grim prognosis, discussions were held with the patient's
daughter, Mrs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Mrs. [**Last Name (STitle) **] expressed on
multiple occasions that her mother would never desire to live
in this condition with her life prolonged by life support
measures. Given her grim overall prognosis, her mother would
prefer to withdrawal care. The code status was changed to
DNR/DNI.
On [**2112-3-7**], after allowing Mrs. [**Last Name (STitle) **] and her son
in-law to visit extensively with the patient, the patient was
extubated and the code status was changed to comfort measures
only. The patient is now currently on a morphine and Ativan
drip at the time of this dictation.
An addendum will later be added.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 9280**]
MEDQUIST36
D: [**2112-3-9**] 01:20
T: [**2112-3-11**] 12:21
JOB#: [**Job Number **]
ICD9 Codes: 0389, 5180, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4659
} | Medical Text: Admission Date: [**2199-10-23**] Discharge Date: [**2199-10-28**]
Date of Birth: [**2124-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dypnea on exertion
Major Surgical or Invasive Procedure:
[**2199-10-23**] - Redo Sternotomy with Aortic Valve Replacement (23mm
[**Company 1543**] Mosaic Ultra Porcine Valve)
History of Present Illness:
75 year old male s/p CABG in [**2187**] now with increased dyspnea on
exertion and found to have significant aortic stenosis. He is
now admitted for surgical management of his aortic valve
stenosis.
Past Medical History:
CAD s/p CABG in [**2187**] and PTCA in [**2198**]
AS, acute systolic heart failure
Hyperlipidemia
HTN
IDDM
Transient Amnesia
Global CVA
Social History:
Retired. Lives with his wife. Denies tobacco or alcohol use.
Family History:
Sister died of CAD at age 65
Physical Exam:
Admission
On physical examination, his pulse is 60. Respirations are 14.
Blood pressure on his right is 130/72 and his left is 125/75.
He is 5'6" tall and weighs 192 lbs. In general, he is in no
acute distress. His skin is warm and dry without clubbing,
cyanosis, or edema. He has a well-healed sternotomy incision.
From HEENT standpoint, his examination is unremarkable. Neck is
supple with full range of motion. Lungs are clear to
auscultation bilaterally. Heart shows a regular rate and rhythm
with a III/VI systolic ejection blowing murmur which radiates to
his bilateral carotids. His abdomen is soft, nondistended, and
nontender with normoactive bowel sounds. Extremities are warm
and well perfused without edema. He does have left lower
extremity vein harvest of his entire leg which appears to be an
open incision. He has no varicosities noted on his right leg on
standing and neurologically, he is grossly intact. Pulses are
2+ throughout.
Discharge
VS T98.7 HR 80SR BP 120/72 RR 20 O2sat 95%-RA
Pertinent Results:
[**2199-10-23**] 03:37PM GLUCOSE-152* NA+-136 K+-4.2
[**2199-10-23**] 03:30PM UREA N-17 CREAT-0.6 CHLORIDE-113* TOTAL
CO2-21*
[**2199-10-23**] 03:30PM WBC-10.2 RBC-3.04* HGB-9.6* HCT-26.4* MCV-87
MCH-31.6 MCHC-36.3* RDW-14.9
[**2199-10-23**] 03:30PM PLT COUNT-132*
[**2199-10-23**] 03:30PM PT-17.8* PTT-39.9* INR(PT)-1.6*
[**2199-10-26**] 07:50AM BLOOD WBC-7.8 RBC-2.88* Hgb-9.2* Hct-25.1*
MCV-87 MCH-31.8 MCHC-36.5* RDW-15.1 Plt Ct-130*
[**2199-10-26**] 07:50AM BLOOD Plt Ct-130*
[**2199-10-23**] 03:30PM BLOOD PT-17.8* PTT-39.9* INR(PT)-1.6*
[**2199-10-26**] 07:50AM BLOOD Glucose-136* UreaN-24* Creat-0.8 Na-136
K-3.2* Cl-97 HCO3-31 AnGap-11
[**2199-10-23**] ECHO
PRE BYPASS The left atrium is moderately dilated. The left
atrium is elongated. No mass/thrombus is seen in the left atrium
or left atrial appendage. The right atrium is 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. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricle displays normal free wall
contractility. The ascending aorta is mildly dilated. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. The non-coronary cusp is immobilized. There
is severe aortic valve stenosis (area 1.0 cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. There is
normal left ventricular systolic function. There is a
bioprosthesis in the aortic position. It is well seated. The
leaflets are not well seen. No aortic insufficiency is
appreciated. There is a maximum gradient of 28 mm Hg and a mean
of 15 mm Hg across the valve at a cardiac output of 5.5 l/m. The
effective orifice area is about 1.6 cm2. The tricuspid
regurgitation is increased to mild. The thoracic aorta appears
intact.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 106928**] M 75 [**2124-8-4**]
Radiology Report CHEST (PA & LAT) Study Date of [**2199-10-27**] 8:38 AM
Final Report
PA AND LATERAL CHEST FROM [**10-27**]
HISTORY: Previous pleural effusion.
IMPRESSION: PA and lateral chest compared to [**10-23**] through
31:
Small bilateral pleural effusion right greater than left has
stabilized since [**10-25**], after increasing since [**10-24**].
Large post-operative
cardiomediastinal silhouette is stable. Azygos distention
suggests elevated central venous pressure or volume but there is
no pulmonary edema. Bibasilar atelectasis is mild and improved
since [**10-25**]. No pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SUN [**2199-10-27**] 11:36 AM
Brief Hospital Course:
Mr. [**Known lastname 54488**] was admitted to the [**Hospital1 18**] on [**2199-10-23**] for elective
surgical management of his aortic valve disease. He was taken
directly to the operating room where he underwent a redo
sternotomy with an aortic valve replacement using a porcine
valve. Please see operative note for details. Postoperatively he
was taken to the intensive care unit for hemodynamic monitoring.
Later that day, he awoke neurologically intact and was
extubated. Beta blockade, aspiriin and his statin were resumed.
On postoperative day two, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
Over the next several days his gradually improved in strength
and mobility. On POD 5 he was discharged to rehabilitation at
[**Hospital3 15644**] in [**Location (un) 47**].
Medications on Admission:
Plavix 75 mg daily, Atenolol 50 mg in the morning and 25 mg in
the evening, Insulin 70/30 20 units in the morning and 6 units
in the evening, a Multivitamin, Zocor 20 mg at bedtime, and
Aspirin 325 mg daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for stent.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 20units QAM/6units QPM units Subcutaneous twice a day.
11. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x5 days then 400mg QD x 7 days then 200mg QD.
13. Lorazepam 0.5 mg Tablet Sig: 0.5 mg PO HS (at bedtime) as
needed.
14. Potassium Chloride 20 mEq Packet Sig: Twenty (20) mEQ PO BID
(2 times a day): 20mEQ [**Hospital1 **] x 10 days then 20mEq QD.
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: 40mg
[**Hospital1 **] x 10days then 40mg QD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
CAD/AS s/p redo CABG/AVR
Hyperlipidemia
HTN
IDDM
Global CVA in past
Transient Amnesia
CABGx3 in [**2187**]
PTCA in [**2198**]
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name (STitle) 4640**] in [**2-26**] weeks. [**Telephone/Fax (1) 20221**]
Please follow-up with Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Completed by:[**2199-10-28**]
ICD9 Codes: 4241, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4660
} | Medical Text: Admission Date: [**2125-5-5**] Discharge Date: [**2125-5-8**]
Date of Birth: [**2097-12-18**] Sex: F
Service:
ADDENDUM: The patient is medically cleared after her last
Mucomyst dose at noon on [**2125-5-8**]. Her liver function tests
have trended downward. The labs upon discharge reveal ALT
1722, AST 253, alkaline phosphatase 64, total bilirubin 1.1,
INR 1.2, PTT 27.8, and PT 13.5. The patient will need an ALT
and AST rechecked on [**2125-5-11**]. If they are higher than the
ones on [**2125-5-8**], please have the patient see Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 497**] at phone# ([**Telephone/Fax (1) 1582**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To Psychiatric Unit.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 49727**]
MEDQUIST36
D: [**2125-5-8**] 11:22
T: [**2125-5-8**] 11:21
JOB#: [**Job Number 49728**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4661
} | Medical Text: Admission Date: [**2141-6-4**] Discharge Date: [**2141-7-6**]
Service:
CHIEF COMPLAINT: Recurrent empyema
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16926**] is an 80 year old
man who presents with shortness of breath and tachycardia.
Mr. [**Known lastname 16926**] had a left thoracoplasty in [**2088**] for
tuberculosis which was performed in the Soviet [**Hospital1 1281**]. He did
well until [**2141-5-3**] when he developed an empyema. An
empyema tube was placed to drain the subsequent empyema.
Over the next several days Mr. [**Known lastname 16926**] developed a
pericardial effusion with evidence of tamponade.
Pericardiocentesis was performed but the right ventricle was
punctured. Subsequently a balloon drain was placed. By [**2141-6-16**], Mr. [**Known lastname 16927**] empyema had not improved. He was
subsequently evaluated by Dr. [**Last Name (STitle) 952**] for surgical
intervention regarding this empyema.
PAST MEDICAL HISTORY: 1. Tuberculosis in [**2084**], status post
left thoracoplasty; 2. Pericardial effusion; 3. Mitral
valve prolapse; 4. Gastric cancer, status post Roux-en-Y
gastrectomy; 5. Multiple pneumonias; 6. Left thoracentesis;
7. Gastroesophageal reflux disease; 8. Nephrolithiasis; 9.
Coronary artery disease, cardiac catheterization performed in
[**2141-3-3**] which revealed mitral valve prolapse, diastolic
dysfunction and coronary artery disease. He may be a
candidate for coronary artery bypass graft in the future.
10. Empyema; 11. Bronchopleural fistula.
SOCIAL HISTORY: No use of tobacco or ethanol.
ALLERGIES: Quinine which causes rash.
OUTPATIENT MEDICATIONS: Metoprolol 12.5 mg b.i.d., Percocet,
Tylenol #3, Vioxx, Triazolam, Colace.
REVIEW OF SYSTEMS: Negative unless otherwise stated above.
PHYSICAL EXAMINATION: Vital signs, temperature 97.2, pulse
68, blood pressure 120/60, respirations 28, oxygen
saturations 96% on 2 liters. Mr. [**Known lastname 16926**] is an elderly
gentleman who appeared his stated age. His heart is regular
in rate and rhythm. He has diffuse crackles which are
greater on the left side. Abdomen is nontender,
nondistended, normoactive bowel sounds. Extremities were
significant for 2+ edema, greater on the right side. He has
a left-sided chest tube.
HOSPITAL COURSE: Mr. [**Known lastname 16926**] was taken to the Operating
Room on [**2141-6-16**] where a left-sided decortication of
empyema was performed, serratus anterior and latissimus dorsi
flaps were placed to close the empyema cavity. The
pericardial window was also constructed. Samples of Mr.
[**Known lastname 16927**] empyema revealed infection by Escherichia coli and
Stenotrophomonas. He was placed on Ceftriaxone which he will
take until [**7-19**] and Bactrim which he will take until [**7-23**] for this infection. Mr. [**Known lastname 16926**] had a prolonged air leak
during his hospital stay and chest tube was left to suction
until [**6-29**]. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were also placed
following his surgery. One [**Location (un) 1661**]-[**Location (un) 1662**] was discontinued on
[**7-2**] and the second [**Location (un) 1661**]-[**Location (un) 1662**] drain was cut and left
to drain to open air. It will be removed at a later visit.
Mr. [**Known lastname 16926**] [**Last Name (Titles) 8337**] his chest tube to water-seal and
subsequently the chest tube was discontinued on [**7-5**], after
being gradually removed. Mr. [**Known lastname 16927**] hospital stay was
also complicated by impaired renal function. His renal
function was gradually improving and will be followed by Dr.
[**First Name (STitle) **] on an outpatient basis. He will also have a visiting
nurse [**First Name (Titles) **] [**Last Name (Titles) **] him on monitoring his renal function. On
[**7-6**], Mr. [**Known lastname 16926**] was doing well and was thought stable to
be discharged from the hospital.
Examination at the time of discharge revealed vital signs of
98.6, pulse 86, blood pressure 128/60, respirations 18,
oxygen saturation 96% on room air. His head is
normocephalic, atraumatic. His neck is supple. His heart is
regular rate and rhythm. His lungs are clear to auscultation
bilaterally with slightly decreased breathsounds over the
area of his incision. Incision and drain sites are clean,
dry and intact. There remains on [**Location (un) 1661**]-[**Location (un) 1662**] drain which
is open to air. His abdomen is soft, nontender, nondistended
with normal bowel sounds. His end-to-side anastomosis are
without cyanosis, clubbing or edema. Mr. [**Known lastname 16926**] had a
PICC line placed on [**6-26**].
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Docusate 100 mg p.o. b.i.d.
4. Ceftriaxone 2 gm intravenously q. 24 hours until [**7-10**]
5. Bactrim double strength one tablet p.o. b.i.d. until [**7-14**]
6. Lansoprazole 30 mg p.o. q.d.
7. Percocet 1 to 2 tablets q. 4 to 6 hours as needed for
pain
8. Lasix 20 mg p.o. q.d. (this medication is only to be
started after specific instructions by a physician)
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged home with
visiting nurse care. The visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] in
general care of Mr. [**Known lastname 16926**] as well as administering
intravenous antibiotics. The visiting nurse will also draw
blood in assistance of monitoring Mr. [**Known lastname 16927**] renal
function.
DISCHARGE DIAGNOSIS:
1. Status post left decortication with serratus and
latissimus flaps
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 16928**]
MEDQUIST36
D: [**2141-7-5**] 19:20
T: [**2141-7-5**] 19:42
JOB#: [**Job Number 16929**]
ICD9 Codes: 5845, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4662
} | Medical Text: Admission Date: [**2138-9-22**] Discharge Date: [**2138-9-30**]
Date of Birth: [**2071-3-16**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Percocet
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Chief complaint:Respiratory distress
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
67F with extensive cardiac history and COPD with
post-intubation tracheal stenosis, s/p tracheal decannulation
and tracheocutaneous fistula. Discharged from ENT service [**9-20**]
after tracheocutaneous fistula closure; her hospital course was
complicated by respiratory failure requiring intubation, MRSA
bacteremia/RLL PNA completed a course of vancomycin, discharged
home with BiPap at night on a course of bactrim. Has history of
pseudomonas PNA. Overnight on evening of admission had acute SOB
after getting up OOB to use bathroom. Reports feeling very
anxious, put on CPAP, able to sleep for an our, awoke again with
severe SOB and presented to OSH ED. Reports jaw pain is her
anginal equivalent but did not experience this during the
episode. No chest pain. Has been coughing, producing white
sputum, though no more than prior to last discharge. Subjective
fevers this afternoon. No chills. Slight right hip pain although
not new. On 2L 02 at home, able to ambulate and climb stairs
without difficulty. No note of LE swelling or recent weight
gain.
Initially presented to [**Hospital 2725**] hospital, found to have RLL PNA
on CXR and new leukocytosis, transfered to [**Hospital1 18**] ED. In our ED,
tried off BiPap, desatted to 80s on NRB. Got CTX, azithromycin
lasix and 500NS at OSH at [**Location (un) **] was flown here. In our ED,
initial VS 98.5 HR 80s BP 95/44 20 98% BiPAP, given 1 dose of
levaquin.
Past Medical History:
-Coronary artery disease s/p CABG in [**2118**] and "recent" PCI
-CHF, last TTE [**2138-9-12**] EF 60% with mild LVH and some focal
hypokinesis at base.
-OSA
-Dyslipidemia
-HTN
-Left total hip replacement-[**1-27**], elective. Complicated
postoperative course with post-operative atrial fibrillation
wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE
UT, and prolonged intubation leading to trach/PEG. Discharged to
chronic wean facility but unable to decannulate. Bronchoscopy
revealed tracheomalacia of subglottic region.
-Supraglottic edema from GERD
-Bipolar disorder
-Depression
-chronic atrial fibrillation, developed postop from THR, not
anticoagulated
-Chronic constipation
-HIT during Fragmin therapy
Social History:
Married. Very supportive husband. When she is not
hospitalized/in rehab, she lives with him. No ETOH or current
smoking. Has 35 pack year smoking history, quit 13 years ago.
Family History:
Depression
Physical Exam:
Vitals: T:96.3 BP:94/51 P:83 R:17 SaO2: 100 BiPap 100% Fi02,
Peep/PS 6/6 TVs 400s.
General: Awake, alert, mildly anxious, tachypneic.
HEENT: NCAT, MM dry. Hoarse voice
Neck: supple, inspiratory wheeze on ascultation of trachea
(louder than in lungs), + JVD with HJR. s/p tracheocutaneous
fistula repair with bandage c/d/i, incision still partially open
with sm amount white drainage. No surrounding erythema. No
crepitus.
Pulmonary: No crackles, inspiratory wheeze. Decreased at right
base.
Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout.
Per ENT note:
FOE: nasopharynx unremarkable. Moderate supraglottic edema at
the level of the false cords. No erythema or exudates. Bilat
true vocal folds with no edema, movement is symmetric. Good
approximation. Scant pooling of thick mucus in the pyriform
sinuses bilat.
Pertinent Results:
WBC 19.3
normal diff (52% neutrophils, no bands)
Hct 41.8
Platelets 631
Na 140 K 5.3 Cl 101 CO2 26 BUN 14 Cr 1.34 Glucose 276
CPK 135
7.28/52/74
UA negative
BNP 340 (nl <100)
Trop I 0.05
.
Imaging:
.
CXR: Persistent RLL infiltrate. Fluid overload worse than prior
([**9-20**])
.
TTE [**2138-9-12**]: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is grossly
normal (LVEF 60%). However, the basal inferior wall is
dyskinetic and tha posterior wall is hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests
impaired relaxation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
EKG:
Sinus rhythm at 92 nl axis, nl intervals. Q waves in II, III,
aVF. TWI V4-V6. Early r-wave progression. No change from prior.
Brief Hospital Course:
MICU COURSE:
Pt was transferred from OSH ED on [**9-22**] in respiratory distress on
bipap. Bipap was weaned off during the first hospital day. CTA
negative for PE. She was initially treated with Vanc/Levo/Zosyn
for ?PNA; these were discontinued on [**9-25**] as no clinical evidence
of infection. She was also initially treated with IV steroids
per ENT for upper airway edema. On [**9-24**] the patient developed
sudden onset respiratory distress and desatted into the 50s.
She was emergently intubated. This was thought to be due to
flash pulmonary edema vs mucous plug. She subsequently did
well, and was taken to the OR for bronchoscopy on [**9-25**]; no upper
airway etiology of her respiratory failure was found. She was
extubated for the procedure but reintubated due to
lethargy/sedation post procedure. She was then extubated on
[**9-26**].
Of note, she developed a small troponin leak in the setting of
her respiratory distress. She was continued on her home cardiac
medications.
MEDICAL FLOOR COURSE:
## Respiratory distress: Patient was stable on xfer to the
floor. Her O2 requirement was weaned and she was back to
baseline 2L NC prior to discharge.
.
## ARF:Ddx includes pre-renal in setting of possible infection
vs ATN/AIN from meds given during last hospitalization.
Stabilized prior to discharge.
.
## CAD: No evidence for ischemia on ecg. Had slight trop leak
in setting of acute resp decompensation in the ICU. Thought not
ACS. Continued home meds.
.
## CHF:Clinically and by CXR and BNP pt appeared moderately
volume overloaded on presentation. She was diuresed and
discharged on home meds.
.
## COPD:Treated for exacerbation
.
## Depression/anxiety:
-ativan needed to be scheduled given her severe anxiety.
-Continued home lamotrigine, quetiapine, sertraline
.
## OSA:
-BiPAP or CPAP at night
.
## Hyperlipidemia:
-Continued statin
.
## Code status: FULL CODE
Medications on Admission:
1. Lactulose prn
2. Sertraline 100 mg daily
3. Docusate
4. Senna
5. Lamotrigine 25 mg Tablet [**Hospital1 **]
6. Quetiapine 25 mg TID
7. Quetiapine 100 mg QHS
8. Albuterol Sulfate Q 6 hours prn
9. Ipratropium-Albuterol Q4 prn
10. Aspirin 81 mg Tablet daily
11. Simvastatin 40 mg daily
12. Lisinopril 5 mg Tablet daily
13. Furosemide 40 mg daily
14. Potassium Chloride 20 mEq daily
15. Metoprolol Tartrate 12.5mg daily
16. Vicodin 5-500 mg Tablet
17. Guaifenesin
18. Bactroban 2 % Ointment Sig
19. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: please take all pills on time and finish entire
course.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Medications:
1. Please use 2-3 liters oxygen and keep saturation > 90% at all
times
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q8H (every 8 hours) as needed for hip pain.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
QID (4 times a day) as needed.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation PRN (as needed).
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
19. Outpatient Physical Therapy
PT for 1-2 visits.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
-possible aspiration pneumonia
-acute respiratory distress
Secondary:
-Coronary artery disease
-Congestive heart failure
-Obstructive sleep apnea
-COPD
-Depression
-Hyperlipidemia
Discharge Condition:
afebrile, satting >90% on 2L NC, ambulating
Discharge Instructions:
You were admitted for respiratory distress. You stayed in the
ICU and stabilized, at which point you were transferred to the
general medicine floor. You are discharged home on your usual
home oxygen therapy. Your lisinopril is held because of
concerns that it would cause your blood pressure to be too low.
Please follow-up with your primary care provider next week
regarding whether or not to restart lisinopril.
1. Please take all medications as prescribed - we made no
changes other than holding your lisinopril.
2. Please attend all follow-up appointments
3. If you develop fevers, chills, chest pain, severe shortness
of breath, nausea, vomiting, or any other concerning symptoms,
please contact your primary provider or report to the Emergency
Room.
Followup Instructions:
Please follow-up with your primary care provider next week
regarding whether or not to restart lisinopril. Dr.[**Name (NI) 105297**]
office number is [**Telephone/Fax (1) **].
Please see physical therapy for 1-2 visits during your first
week after discharge.
ICD9 Codes: 5849, 7907, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4663
} | Medical Text: Admission Date: [**2108-6-14**] Discharge Date: [**2108-6-18**]
Date of Birth: [**2034-7-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Tetracycline / Keflex / Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
subdural hematoma
Major Surgical or Invasive Procedure:
[**2108-6-14**] Right craniotomy for subdural hematoma
History of Present Illness:
Pt with elective admission for SDH after fall in [**2108-4-28**].
Past Medical History:
Charcot [**Doctor Last Name **] Tooth Disease
HTN
Anxiety
peripheral neuropathy
osteoporosis
GERD
paralyzed phrenic nerve
recent corneal surgery bilaterally
Social History:
lives in [**Hospital3 **] facility, wheelchair bound. Daughter
[**Name (NI) **] is 1st contact [**Telephone/Fax (1) 85406**].
Denies tobacco/etoh or recreational drug use.
Family History:
non-contributory
Physical Exam:
ON discharge
Awake alert oriented x 3. CN II-XII intact. Motor full except
grips [**4-2**] and LE's not antigravity.
Pertinent Results:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 85407**] F 73 [**2034-7-24**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2108-6-14**]
3:33 PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG CC1A [**2108-6-14**] 3:33 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85408**]
Reason: please evaluate for post-operative bleeding; s/o right
crani
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with sdh
REASON FOR THIS EXAMINATION:
please evaluate for post-operative bleeding; s/o right crani
for sdh
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: [**First Name9 (NamePattern2) 85409**] [**Doctor First Name **] [**2108-6-14**] 5:33 PM
Status post evacuation of right SDH, with no evidence of
posoperative bleed or
large infarct. improvement of leftward shift of midline
structures.
Final Report
INDICATION: Subdural hematoma, postoperative evacuation.
COMPARISON: CT available from [**5-15**] through [**2108-6-12**].
TECHNIQUE: MDCT-acquired axial images of the head were obtained
without use
of IV contrast.
FINDINGS: The patient is status post evacuation of a right-sided
subdural
hematoma. Post-surgical changes are present, including a new
right calvarial
defect at the craniotomy site, overlying skin staples,
associated soft tissue
swelling, and mild pneumocephalus. There is subsequent interval
decrease of a
previously seen right vertex subdural collection. This has
resulted in
interval improvement of a left-sided shift of midline structures
(4 mm, 2:18).
There is no evidence of new hemorrhage or large vascular
territorial
infarction. Ventricles and sulci are unchanged in configuration.
Minimal
mucosal thickening of the left maxillary sinus with mild fluid
within the
mastoid air cells (2:4) are unchanged.
IMPRESSION: Status post right-sided evacuation of subdural
hematoma, with
improvement of leftward midline shift, and no evidence of
hemorrhage or large
vascular territorial infarction.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: FRI [**2108-6-15**] 1:53 PM
Imaging Lab
Brief Hospital Course:
PT was admitted electively for evacuation of SDH in [**2108-4-28**].
She underwent the right sided craniotomy for evacuation without
complication. She was transfered to the ICU the evening after
surgery for rapid desaturation. In the ICU she received
diltiazem for rapid afib. She was transitioned from iv to po
dilt. and did well. She was stable and then was able to return
to the floor the next day. The patient has been complaining of
cough with secretions but follow up Xrays last being [**6-18**] showed
no signs of pneumonia.
The patient had intermittent hyponatremia her sodium levels were
132-135 while hospitalized last being 133 on discharge. She is
receiving salt tabs.
She c/o difficutly swallowing and was evaluted by speech and
swallow. They recommended: 1.PO [**Month/Year (2) **] of thin liquids and moist,
soft solids. 2. Pills crushed w/ puree. 3. 1:1 supervision to
assist w/ feeding. 4. If there are concerns for aspiration on
this [**Month/Year (2) **], recommend follow-up by speech and swallow swallow
evaluation at rehab. 5. Q4 oral care.
She was seen this am and is stable for d/c from a neurosurgical
standpoint and agrees with this plan.
Medications on Admission:
Citalopram, Tolterodine, Bupropion
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours).
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO every
twelve (12) hours.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
16. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6594**]
Discharge Diagnosis:
removal Right subdural hematoma
dysphagia
ATRIAL FIBRILLATION / NEW ONSET
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please have your sutures removed on [**2108-6-25**] (You may have them
removed at rehab)
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
- YOU HAD AN IRREGULAR HEART RHYTHM IN THE HOSPITAL CALLED
ATRIAL FIBRILLATION. YOU CONVERTED TO REGULAR SINUS RHYTHM WITH
DILTIAZEM. YOU NEED TO FOLLOW UP WITH YOUR PRIMARY CARE
PHYSICIAN REGARDING YOUR NEW DIAGNOSIS.
Completed by:[**2108-6-18**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4664
} | Medical Text: Admission Date: [**2150-7-3**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2070-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worsening aphasia, right sided weakness, and left facial droop.
Major Surgical or Invasive Procedure:
[**2150-7-4**] left crani with drain placement
[**2150-7-15**] Left sided extended craniotomy for re-evacuation of
subdural hematoma
[**2150-7-15**] Central line
History of Present Illness:
Mr [**Known lastname **] is a 80M who is well known to our service. He is s/p
left craniotomy for SDH evacuation on [**2150-6-8**]. He had an
unremarkable post-op course and was sent home with services.
Subsequently he has returned to the ER multiple times. On
[**2150-6-18**], he returned with increased headache, the CT at that
time showed a slight increase in his L hygroma, he was admitted
to neurology as no surgery was indicated and discharged home. He
once again presented to the ER on [**7-2**] with c/o slurred speech
and right hand weakness, he was admitted for overnight
observation then discharged home. He returns to the ER today
with c/o
worsening aphasia, right sided weakness, and left facial droop.
Neurology was consulted as well.
Past Medical History:
diabetes, prostate cancer status post radiation, hypertension,
GERD, hypercholesterolemia. He has had previous craniotomy on
the right side for an intracranial hemorrhage. L SDH (evacuated
[**2150-6-8**])
Social History:
Retired, used to work as a cabinetmaker. Lives
with his wife. [**Name (NI) **] tobacco use. Occasional ETOH. Denies illicits
Family History:
Not known to the patient
Physical Exam:
Awake, alert, left facial droop, tongue midline, L pupil 4-2mm,
R
pupil 3-2mm, EOM difficult to assess secondary to cooperation,
aphasic, unable to name objects, unable to answer orientation
questions, comprehension appears intact, + commands L>R. Left
side was full motor, RUE: delt 0/5, bic [**4-4**], tri [**4-4**], R grasp
[**3-5**]
RLE: IP/H [**3-5**], quad [**4-4**]. Sensation intact appears intact to
pain.
PHYSICAL EXAM UPON DISCHARGE:
AVSS
NAD, AxOx4, nods head and answers questions appropriately
although complex answers take significant effort to produce
words
significant expressive aphasia, comprehension intact
CNII-XII intact, no facial asymmetry, tongue midline
5- UE strength on R, 5 on L
5- LE strength on R, 4 on L
sensation grossly intact bilat.
extrems wwp, 2+ cr bilat.
Pertinent Results:
[**2150-7-3**]: NCHCT IMPRESSION: No change since prior study [**2150-7-1**].
[**2150-7-3**]: AP AND LATERAL VIEWS OF THE CHEST: There are again low
lung volumes causing bibasilar atelectasis and crowding of the
pulmonary vasculature. No focal opacities concerning for
infectious process are present. No pleural effusion or
pneumothorax is noted. Aorta is tortous, unchanged.
[**2150-7-5**] CT head
Post-surgical changes related to left frontal craniotomy as
described above. In comparison to [**2150-7-3**] exam, there is no
significant change in bilateral subdural collections.
Persistent 6-mm rightward shift of normally midline structures
[**2150-7-6**] CT head
1. Post-surgical changes related to left craniotomy with
interval removal of drain and slight decrease in size of
bilateral subdural collections.
2. Persistent 6 mm rightward shift of normally midline
structures, stable
from previous exam
[**2150-7-7**] EEG
This is an abnormal continuous video EEG telemetry due to
frequent intermittent left posterior slowing mostly in the delta
range
admixed with theta activity. The posterior dominant rhythm on
the left shows attenuation of voltage compared to the right
side. There are two pushbutton activations and neither of them
show EEG changes to suggest seizure. Automated and routine
sampling fails to show any epileptiform activity.
CT head [**2150-7-9**]
1. Study limited by streak artifact from overlying EEG leads.
The previously seen left subdural hematoma now has more
posterior extension, unclear if thisis due to redistribution.
Would consider continued followup.
2. Persistent 8-mm rightward shift of normally midline
structures,
approximately stable from previous exam
Echo [**2150-7-10**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. 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. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
MRI Brain/MRA Brain and Neck [**2150-7-10**]
1. No acute infarction.
2. Similar appearance of moderate-sized left subdural
collection, with
hemorrhagic component. Extensive left-sided pachymeningeal
enhancement with appearance of transudation of contrast to the
subjacent CSF space.
3. Post-surgical changes, including small post-operative
pneumocephalus
account for the described MR abnormality. Prominent left-sided
cortical
vessels. No definite leptomeningeal or mass-like enhancement.
4. Tortuous intracranial vessels, as described, but no aneurysm
larger than 3 mm, arteriovenous malformation or flow-limiting
stenosis. Normal cervical vessels.
Carotid Series [**2150-7-10**]
Findings consistent with less than 40% stenosis bilaterally.
CXR [**2150-7-10**]
Again seen is bibasilar atelectasis. A small infectious
infiltrate
at either base cannot be totally excluded; however, the overall
appearance is similar to that from one week prior. The upper
lungs are clear. The aorta is tortuous, unchanged. There
continues to be mild cardiomegaly.
CT Head [**2150-7-11**]
Persistent left subdural hematoma measuring up to 25 mm in
maximal dimension in the inner table of skull with mass effect
on the adjacent sulci, greatest at the left frontal lobe, as
well as persistent rightward shift of normally midline
structures by 9mm, compared to 8 mm previously. Post left
frontal craniotomy changes are again noted with pneumocephalus.
Continued followup is recommended.
EEG [**7-12**]
This continuous EEG recording captured three automated events
without electrographic correlate. No epileptiform activity was
seen. The
presence of an asymmetric background typically correlates with
subcortical
abnormalities under the slower hemisphere, which, in this case,
would be the left.
[**7-14**] CT head: Large left-sided subdural hematoma slightly larger
since [**2150-7-11**]. Mild increase in the mass effect and rightward
shift of midline structures.
[**7-14**] Chest Xray: PA and lateral images of the chest are
essentially unchanged from [**7-3**]. There are again seen low
lung volumes and bibasilar opacities which are unchanged. There
is no evidence of new infiltrate or consolidation.
Cardiomediastinal silhouette is unchanged. Visualized osseous
structures are unremarkable.
[**7-15**] CT head - Status post evacuation of left hemispheric
subdural hematoma, with minimum residual left subdural fluid.
Significant improvement in the mass effect on the left
hemisphere and rightward shift of midline structures.
[**7-16**] CT Head - No change
[**7-17**] - Slight increase in in residual blood in left hemispheric
subdural collection. Mild mass effect and 5-mm rightward shift
of midline structures are unchanged.
[**7-18**] NCHCT
No changes since previous scan. No new hemorrhage and stable
midline shift
Brief Hospital Course:
The patient was admitted the ICU on [**7-3**] for close neurological
observation. He was prepped for surgery. On [**7-4**] he was taken to
the operating room and underwent a left cranectomy with drainage
of the hygroma with drain left in. This was performed without
complication. Post operatively the patient did well and was
transferred to the surgical ICU for monitoring. Repeat head CT
was stable with persistent 6-mm rightward shift.
on [**7-6**] the patient's exam was significantly improved from the
day of presentation with return of upper right extremity
strength, improved word finding ability and only minimal right
nasolabial fold flattening. He was draining minimal amounts of
serosanguinous fluid and drain was removed. Repeat CT head was
done in the afternoon for fluctuating neurologica exam.
Pneumocephalus and persisten SDH was noted. On [**7-7**] he was doing
well with only mild right pronator drift.
On [**7-7**] he began to have episodes of dysarthria and RUE weakness
that would last about 15 minutes with clear episodes of
improvement. Neurology was called and EEG was in place. There
was no clear seizures on report. He had a repeat CT head on [**7-9**]
that showed increased posterior expansion of the subdural
hematoma but stable midline shift. [**Last Name (un) **] continued to follow
and make recommendations for his diabetes management.
On [**7-10**] the patient had an MRI/MRA which showed no infarct and
no vascular abnormalities. Echocardiogram was also done and was
normal and carotid ultrasounds showed less than 40% stenosis
bilaterally. That evening the patient was noted to be more
confused with increasingly frequency episodes of aphasia and
right arm weakness. Urinalysis and blood cultures were sent to
check for underlying infection and continuous EEG was resumed on
[**7-11**]. The patient also had a repeat CT with reconstructions that
showed a persistent L SDH measuring 2.5cm in maximal thickness
with 9mm of MLS. On [**7-12**] he remained stable and on [**7-13**] EEG was
stopped as he was not noted to have any seizure activity. His
Antieplileptic regimen was changed to Keppra only as well.
On [**7-14**] his right arm was noted to be decreased in strength with
proximal weakness of [**12-1**] and distal weakness of 3. Ct head was
obtained that showed slight increase in the size of the SDH with
slight increase in mass effect and edema. In the evening of
[**7-14**] the patient's strength improved to [**4-4**] however he continued
to be dysphasic. Family meeting was held to discuss the option
of a third surgery to evacuate the hematoma and the family and
patient decided to defer surgery for now in the setting of his
improved strength.
On [**7-15**] patient's exam again worsened, he was having difficulty
speaking and was unable to move to his right arm. He was taken
to the operating room and underwent a extended left
frontal/temporal craniotomy for subdural hematoma evacuation.
Post operatively he was transferred to the ICU intubaed. He had
a head CT immediately after which showed much improvement in the
midline shift.
On [**7-16**] The patient remained intubated overnight due to concerns
that he was slow to awake. He was extubated successfully POD #1.
His subdural drain was removed. His exam revealed improved right
arm strength and facial droop but continued aphasia. Later in
the day the patient became tachycardic to the 120s. His cardiac
enzymes were negative but he had some ST changes concerning for
demand ischemia.
on [**7-17**] He had lower extremity ultrasounds which was negative
for DVTs. As no clear cause for sinus tachycardia could be
found, it was thought that is was most likely due to hydralazine
that was being given for blood pressure control. This was
discontinued and he was started on metoprolol. He started
working with physical and speech therapy.
On [**7-18**] Another repeat CT head was obtained which showed no
changes.
On [**7-19**], patient remained stable, more conversant and with good
strength. He was OOB with assistance and PT was consulted.
On [**7-20**] the patient was tranfered to the floor and continued to
improve with regards to his aphasia. The patient was discharged
the following day in good condition.
Medications on Admission:
Levetiracetam 500 [**Hospital1 **], Losartan 50 daily, Omeprazole
40 daily, Pravastatin 40 daily, Metformin 1700 qam and 850 qpm,
not sure if still taking Glipizide 10 daily, Finasteride 5mg
daily, Acetaminophen prn
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Losartan Potassium 50 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN headache
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain/ fever
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Metoprolol Tartrate 25 mg PO BID
Hold sbp <100, HR<60
12. Multivitamins 1 TAB PO DAILY
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Senna 1 TAB PO BID
16. GlipiZIDE 10 mg PO DAILY
17. MetFORMIN (Glucophage) 1700 mg PO BID
1700mg in AM 850 in PM
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
subdural hygroma
hyperglycemia
transient hemiparesis
aphasia
Discharge Condition:
Mental Status: Clear and coherent (expressive aphasia,
comprehension intact)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Craniotomy for Hemorrhage
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? **Your wound was closed with sutures. You may wash your hair
only after sutures have been removed.
?????? ?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**9-13**] days(from your date of
surgery) for removal of your sutures. This appointment can be
made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????**You may also have them removed at your rehab facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2150-7-21**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4665
} | Medical Text: Admission Date: [**2168-10-14**] Discharge Date: [**2168-11-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ORIF of left hip
History of Present Illness:
86 [**Hospital **] [**Hospital 45534**] transferred from [**Hospital3 **] after
unwitnessed fall/L hip fracture & ? C-spine injury (? fracture
of C1 and C2), initially scheduled for [**Hospital3 **]-trauma hip surgery.
In ED, [**Hospital3 **]/trauma surgery plan for L femoral neck fracture
and ? cervical vertebrae injury, admitted to medicine for
syncopal episode and pre-op assessment.
On [**10-15**] AM, medicine administered beta blockade in
preparation for OR, SBPs/HR and hemodynamics stable overnight,
with admission hct 38. In PACU, noted to have SBP in 70s,
required peripheral dobutamine and neosynephrine to maintain
MAPs >60, hct drop to 26.4 --> transfused 1 unit, given 1L [**Hospital **]
transferred to MICU.
Upon transfer to MICU at 1130am, left subclavian/axillary
line placed with stabilization of systolic pressures >100,
transitioned to levophed. At 12:31, pt had bradycardia -->
asystolic arrest, had immediate CPR with intubation, 2 epi, 1
atropine, with resumption of pulse and pressure at 12:39pm. EKG
showed st-depressions v3-v5, transfused 1 unit PRBCs with hct
rise to 26.7, given 1L NS, repleted calcium/magnesium, levophed
administered to maintain MAPs>60, lactate 4.0 - 5.0, R-A line
placed. CXR showed no pulmonary edema, ?globular heart, bedside
echo initial read showed no tamponade with EF~30%.
Past Medical History:
1. Alzheimer's with significant brain atrophy
2. Afib for 8 yrs on coumadin
3. Cirrhosis
4. urinary and fecal incontinence
5. depression
6. Asthma
7. Chronic CHF - alcoholic cardiomyopathy
8. chronic constipation
9. previous fracture of the cervical bends - stabilized by
neurosurgery. Healed.
10. hx of falls
11. GERD
12. osteoarthritis
Social History:
Lives in [**Location (un) 5503**]. He is demented at baseline and wheelchair
bound. Granddaughter [**Name (NI) **] #[**Telephone/Fax (1) 75243**].
Family History:
Non-contributory
Physical Exam:
VS:BP 95/57 HR95 RR13-17, sats 100% on RA AC TV 500 RR 14 Fio2
40%. CVP 22-26.
GEN: WDWN elderly male in NAD.
HEENT: NCAT, pupils 2mm, nonreactive, no scleral icterus. OP
clear, MM dry.
NECK: No LAD, no carotid bruits.
CV: Irreg irreg, tachy. Cannot appreciate any murmurs.
PULM: CTA anteriorly, at bases. No crackles/wheezes.
ABD: Soft, NTND, + BS, no HSM.
EXT: Cool upper/lower extremities. 2+ DP pulses bilaterally.
Has warmth and some tightness but no visible ecchymosis over L
thigh. ?livedo reticularis anterior right thigh.
Pertinent Results:
STUDIES:
[**2168-10-12**]: report from [**Hospital3 15402**] head CT [**10-12**]
[**2168-10-13**]: CT head scan w/o contrast at [**Hospital3 15402**] : No hemorrhage
or mass effect. See report in chart.
.
[**2168-10-13**]: CT of cervical spine at [**Hospital3 15402**]: Good healing of the
fracture at the base of the odontoid process. There is evidence
of a fracture on the right side of the body of C2 posteriorly
and superiorly wher there was a fracture previously so I do not
know if this is due to poor healing or a new fracture. There
appears to be an undisplaced fracture involving the right side
of the posterior arach of C2 which I cannot identify on the last
exam. Otherwise, there is a cervical spondylosis.
.
[**2168-10-14**] CXR: No evidence of acute cardiopulmonary process.
.
[**2168-10-14**] L HIP/FEMUR XR:
1. Left intertrochanteric fracture with a medially displaced
lesser
trochanter fracture fragment.
2. Severe left knee osteoarthritis
[**2168-11-2**] 07:00AM BLOOD WBC-6.7 RBC-2.97* Hgb-9.3* Hct-29.3*
MCV-99* MCH-31.2 MCHC-31.6 RDW-19.1* Plt Ct-473*
[**2168-10-25**] 06:50AM BLOOD Neuts-62 Bands-1 Lymphs-25 Monos-10 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2168-11-2**] 07:00AM BLOOD PT-14.6* INR(PT)-1.3*
[**2168-11-2**] 07:00AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2168-11-1**] 06:40AM BLOOD ALT-30 AST-31 LD(LDH)-353* AlkPhos-221*
TotBili-1.7*
[**2168-11-2**] 07:00AM BLOOD TotBili-1.4
[**2168-10-16**] 12:57PM BLOOD CK-MB-6 cTropnT-<0.01
[**2168-10-29**] 10:10AM BLOOD Lipase-44
[**2168-11-2**] 07:00AM BLOOD Mg-1.9
[**2168-10-29**] 10:10AM BLOOD calTIBC-238* Ferritn-397 TRF-183*
.
Microbiology:
AEROBIC BOTTLE (Final [**2168-10-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] CC6D AT 21:45 ON
[**2168-10-22**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
ANAEROBIC BOTTLE (Final [**2168-10-24**]):
CITROBACTER FREUNDII COMPLEX. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 R
TOBRAMYCIN------------ <=1 S
.
GRAM STAIN (Final [**2168-10-21**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2168-10-23**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Overall course: patient was brought to hospital with hip
fracture, admitted to medicine. Due to hemodynamic instability
was transferred to MICU where found to have HCT drop of 10pts.
Subsequently had bradycardic arrest, successful resuscitation.
Went to the OR and had ORIF of left hip. Subsequently became
septic with E coli in sputum, Citrobacter in blood, started on
ABX. Also started on metronidazole for Cdiff but d/c'd when
toxins came back negative. Electrophysiology evaluated the
patient and determined that while no intervention is required
now outpatient followup in [**12-29**] months is indicated.
1). Hip Fracture: According to the family, the patient fell out
of his bed while trying to get up; he is non-ambulatory at
baseline. The patient was taken to the emergency room on [**10-18**]
for an ORIF of his left hip. He tolerated the procedure well
and was placed on Lovenox prophylaxis afterwards. He continued
to work with occupation and physical therapy during his stay.
He will continue Lovenox until his INR is therapeutic (between
2.0 and 3.0).
2). Sepsis/Hypotension: The patient was hypotensive requiring a
MICU transfer for pressors in the setting of a 10 point
hematocrit drop over an 18 hour period shortly after admission.
The HCT drop was thought to be secondary to bleeding into his
left thigh after his fracture. He has a CTA which was negative
for pulmonary embolus and bilateral lower extremity ultrasounds
that did not show clot. A cortisol stim test was negative for
adrenal insufficiency. His blood cultures grew Citrobacter
freundii x 2 and coag negative staph x 1; a sputum culture grew
out E Coli. The cultures were resistant to piperacillin and
ciprofloxacin; the patient was started on cefepime for coverage.
3). Atrial fibrillation with Rapid Ventricular
Response/Bradycardia/Asystolic Arrest: The patient had a
witnessed bradycardic episode in the MICU with asystole. Chest
compressions were performed and the patient was resuscitated.
An electrophysiology consult was obtained and the etiology of
his bradycardia was thought to be secondary to excessive beta
blockade and possible sick sinus. He was stabilized and slowly
restarted on beta blocker therapy and digoxin therapy. After
transfer from the ICU the patient began to have RVR to the
150's; the digoxin was stopped and he was transitioned to
longer-acting beta blockade with atenolol. The patient began to
have occasional pauses between 1.5 and 2.8 seconds on telemetry
which were entire asymptomatic. Electrophysiology was
re-consulted and the patient's beta blockade was titrated
downwards. He will be discharged on beta blocker therapy with
electrophysiology follow up in [**1-30**] months. Per the PCP request
the patient the patient was restarted on Coumadin for long-term
anticoagulation.
4). Anemia: The patient's HCT was low in the context of sepsis,
bleeding and his hip surgery. It remained stable between 25 and
30 for the last week of his stay. His iron studies reflect a
mixed picture, but he has a strong reticulocytosis. He should
follow up with his primary care physician once this acute
episode has resolved.
5). Acute renal failure: The patient had acute renal failure
upon presentation with a creatinine of 1.4 and a rise to 2.0
post-code. This was most likely due to poor perfusion and a
hypodynamic state in the context of his bleed. Once he was
resuscitated his acute renal failure resolved.
6). Alzheimer's Dementia: The patient has dementia at baseline.
He had occasional episodes of delirium in the context of his
sepsis but he improved with antibiotic therapy.
7). Cardiomyopathy/Chronic Systolic Congestive Heart Failure:
The patient had his medications held but had his beta blocker
and captopril reinitiated when he was on the floor.
8). Elevated liver function tests: The patient had elevated
liver function tests upon transfer to the floor; a RUQ
ultrasound and CT abdomen were negative. A liver consult was
obtained and his hepatitis panel was negative. His Tbili slowly
resolved, but he should have his liver function tested a week
after discharge.
Medications on Admission:
Warfarin 3 mg DAILY
Coreg 6.35 mg [**Hospital1 **]
Capoten 25 mg [**Hospital1 **]
Lasix 20 mg DAILY
Potassium Cholride 20 mEq DAILY
Duragesic Patch 50 mcg Q3days
Oxycodone/Acetominophen 10/325 mg [**Hospital1 **]
Omperazole 20 mg DAILY
Fluoxetine 20 mg DAILY
Mag Citrate qwednesday
Nortryptyline 25 mg QHS
Aricept 10 mg QHS
Duo Neb
Lactulose 60 ml DAILY
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): may discontinue once INR is
between 2 and 3.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10ml PO BID (2
times a day) as needed.
3. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 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.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
the highlander
Discharge Diagnosis:
Sepsis
Hip Fracture s/p ORIF
Musculoskeletal Chest Pain
Anemia
Atrial fibrillation with rapid ventricular response
chronic systolic congestive heart failure
Alzheimer's Dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue to take your medications as prescribed. You
were started on coumadin. Please have your INR checked every
2-3 days and titrate with a goal INR between 2 and 3. Once your
INR has reached therapeutic levels you may discontinue the
lovenox therapy.
You should have your liver function tests evaluated in a week.
You will continue to have occasional fast heart beats and
occasional slow beats. If these are not asymptomatic you should
contact a physician. [**Name10 (NameIs) **] addition, if you develop fevers,
chills, or any other concerning symptoms please contact a
physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7568**] [**Telephone/Fax (1) 75244**] in two weeks.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] [**Telephone/Fax (1) 902**]
(electrophysiology) in [**1-30**] months.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-11-10**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-11-10**] 11:30
Completed by:[**2168-11-3**]
ICD9 Codes: 4275, 5849, 5990, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4666
} | Medical Text: Admission Date: [**2121-8-7**] Discharge Date: [**2121-8-16**]
Date of Birth: [**2055-2-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
GI bleeding/melena
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
65 F h/o HTN, AFIB, s/p AVR/MVR [**12-27**] RF, developed low back pain
and dark stools 3d PTA. She presented to PCP ~2d PTA, and left a
stool sample. Labs revealed INR=4.7, HCT=32->31 (baseline
38-10), and pt was called earlier on morning of admission and
told to present to ED. Pt denied diarrhaea, constipation, recent
NSAID use, or regular alcohol consumption. In the ED, VS: 97.8
70 102/59 16 97%RA. She was guiaic positive rectally. NGL was
negative. She was given 1L IVF and started on protonix.
.
She was in the MICU with stable HD and stable hct since that
time. GI was consulted and plans for scope likely on Monday. She
is on a heparin gtt to allow her INR to drift down in
preparation for procedure.
Past Medical History:
aortic valve replacement, mitral valve replacement in [**1-27**]
secondary to rheumatic heart disease
hypertension
atrial fibrillation on coumadin
hyperlipidemia
herniated lumbar disc disease
foraminal stenosis
chronic back pain
Social History:
Denies alcohol use, has been using snuff tobacco since she was
young, no smoking hx, denies IVDU. retired housekeeper.
Emigrated from [**Country **] ~20 yrs ago.
Family History:
No known history of blood clotting disorder.
Physical Exam:
VS: 97.0 70 128/63 19 96%RA.
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM,
CV: RRR, nl s1, s2, no m/r/g.
PULM: CTAB, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL.
NEURO: alert & oriented x 3, CN II-XII grossly intact. [**3-29**]
strength symmetric UE and LE.
Pertinent Results:
HEMATOLOGY
[**2121-8-7**] 12:45PM WBC-5.7 RBC-3.36* HGB-10.7* HCT-31.7* MCV-94
MCH-32.0 MCHC-33.9 RDW-14.3
[**2121-8-7**] 12:45PM NEUTS-60.4 LYMPHS-34.1 MONOS-4.1 EOS-1.2
BASOS-0.2
[**2121-8-7**] 12:45PM PLT COUNT-247
[**2121-8-7**] 12:45PM PT-27.0* PTT-31.3 INR(PT)-2.8*
[**2121-8-7**] 05:36PM RET AUT-4.1*
[**2121-8-7**] 05:36PM PT-32.6* PTT->150* INR(PT)-3.5*
.
[**2121-8-7**] 05:36PM WBC-7.6 RBC-3.00* HGB-9.7* HCT-28.0* MCV-93
MCH-32.5* MCHC-34.9 RDW-14.4
[**2121-8-7**] 05:36PM PLT COUNT-206
.
[**2121-8-7**] 11:32PM WBC-6.9 RBC-2.95* HGB-9.5* HCT-27.5* MCV-93
MCH-32.1* MCHC-34.5 RDW-14.3
[**2121-8-7**] 11:32PM PLT COUNT-196
[**2121-8-7**] 11:32PM PTT-36.1*
.
[**2121-8-7**] 05:36PM TOT BILI-1.2
[**2121-8-7**] 05:36PM IRON-58
[**2121-8-7**] 05:36PM calTIBC-321 FERRITIN-22 TRF-247
.
CHEMISTRIES.
[**2121-8-7**] 12:45PM GLUCOSE-99 UREA N-18 CREAT-1.0 SODIUM-143
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-30 ANION GAP-10
.
URINE
[**2121-8-7**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2121-8-7**] 02:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
.
.
STUDIES:
[**2121-8-7**] EKG: NSR, prolonged av-conduction, no STE/STD.
.
[**7-28**] TTE:
The left atrium is moderately dilated. The left atrium is
elongated. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened. There is mild aortic valve stenosis. Moderate
(2+) aortic regurgitation is seen. The mitral valve shows
characteristic rheumatic deformity with fused commissures and
tethering of leaflet motion. There is moderate mitral stenosis.
Due to co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Moderate (2+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Brief Hospital Course:
65 F h/o afib, htn, AVR/MVR, presented with 3 day history of
melena, elevated INR, stable hct, transferred from MICU to
medicine service.
.
# GIB - To evaluate her GI bleeding, an EGD and colonoscopy were
performed. Colonoscopy clear. EGD shows antral erosions. H.
pylori studies were negative. Anticoag risk: bigger cardiac/CVA
risk of not anticoagulating, compared to anticoagulation risk
for GIB. She was put on a planned course of [**Hospital1 **] PPI for one
month, and daily PPI thereafter. She was bridged back to
coumadin with a heparin drip, a process which took considerable
time.
.
# HTN: held ACE and BB for concern for possible new bleeding and
risk for hypotension, monitored closely. Normotensive with
regular rate in the hospital, and did not restart these
medicines in the hospital or on discharge.
.
## Mechanical heart valve: Was on heparin bridge while off
coumadin in preparation for procedure, and until therapeutic
after EGD/[**Last Name (un) **]. This latter heparin to coumadin bridge took
considerable time and was the main reason for the length of her
admission. She was discharged with an INR of 2.6.
.
#FEN: Heart healthy diet after [**Last Name (un) 12964**].
.
#PPx:
Heparin/coumadin, as above; PPI, as above.
.
#CODE: FULL
.
#DISPO: to home once INR >2.5
#COMM: With patient and family. Main family contact: daughter
[**Telephone/Fax (1) 12965**], [**First Name8 (NamePattern2) 12966**] [**Last Name (NamePattern1) 12967**]. Used [**Location 7972**] Creole
translators for daily H+Ps and discussions with patient.
Medications on Admission:
toprol xl 50 mg po qdaily
quinipril 20 mg po qdaily
lipitor 10mg po qdaily
protonix 40 mg po qdaily
lasix 20 mg po qdaily
colace 100mg po qdaily
ativan 1.5mg po qhs
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for back pain.
Disp:*1 tube* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as
needed for antral erosions for 1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Talk to your doctor about whether you should change your dose of
warfarin.
.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed secondary to supratherapeutic INR and antral erosions.
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because you were having
bleeding in your gastrointestinal system. The doctors performed
two [**Name5 (PTitle) 12964**]; one looked inside your large intestine, and the
other looked inside your stomach. The study that looked inside
your stomach showed that there were some spots in your stomach
lining that had eroded away, and were bleeding.
.
You have been taking coumadin (also called warfarin), a
blood-thinning medicine that is important for you because you
have mechanical heart valves. Coumadin helps to prevent strokes
in people with these heart valves. But coumadin can also make it
easier to bleed. It is likely that with too high a coumadin
level, the erosions in your stomach bled more than they would
have otherwise.
.
You should continue to take the coumadin, and to get your blood
checked regularly. Your doctor or nurse may need to change the
dosage in order to make sure the coumadin level is correct.
.
Sometimes leafy green vegetables can lower your coumadin level.
If eating leafy green vegetables is important in your diet, talk
to your doctor about trying to find ways that you can eat your
vegetables and have a stable coumadin level. For now, avoid
leafy green vegetables like kale and collard greens until you
can discuss this with your doctor.
Followup Instructions:
Make an appointment with Dr [**Last Name (STitle) **] as soon as possible-- they
need to check your blood levels of Coumadin, the blood thinner.
Make an appointment with the gastrointestinal clinic for one
month from now.
ICD9 Codes: 4280, 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4667
} | Medical Text: Admission Date: [**2134-9-11**] Discharge Date: [**2134-9-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
cardiac catheterization with placement of three stents and IABP.
Swan catheter placement.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 87 yo M with chronic kidney disease
s/p AV Graft placement [**8-2**], stroke, hypertension, diabetes, and
peripheral vascular disease presents with chest pain and
shortness of breath. He reports that his chest pain began
approximately one week ago. During the week it has gotten worse.
It is substernal, radiating to left shoulder, especially with
inspiration. It is associated with shortness of breath. He came
to the hospital today because the pain was much worse, [**9-6**]. In
addition, he noted today black stools. He has been taking iron.
He reports lightheadedness. Denies nausea, vomiting,
diaphoresis, arm paresthesias. He has also noticed a cough
recently but has not been able to produce sputum (though he
feels congested).
.
The pt was seen in Geriatric Urgent Care clinic on [**9-11**] for
dyspnea. He noted worsening in the supine position. An CXR at
the time to evaluate possible CHF showed "No evidence of
congestive heart failure or pneumonia. Elevation of the right
hemidiaphragm".
.
In the ED, the patient was given 80mg IV lasix x 2 with UOP of
100-200cc. He received nitropaste, lopressor IV and [**Last Name (LF) **], [**First Name3 (LF) **], and
morphine, and was started on a nitro gtt. Heparin was started as
well, and 1 unit PRBCs was transfused. He was given one dose of
protonix, levofloxacin and . BPs were in the 110s-120s/50s-60s,
HR 70s-80s. Renal, GI, and cardiology consults were called. The
patient continued to report [**9-6**] pain, eventually decreased to
[**6-6**] with titration of the nitro gtt. On arrival in the CCU, he
still reported [**6-6**] pain. He was on nitro at 120 mcg/min and
heparin at 850 units/hr.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertensive nephrosclerosis s/p right
upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis.
Graft placement was complicated by cellulitis, for which he was
treated with keflex
2. DM, on glyburide and glipizide at home
3. HTN, on clonidine, lisinopril, nifedipine
4. PVD s/p aortic bypass
5. CVA, with residual weakness of his left side
6. R CEA
7. Secondary hyperparathyroidism
8. Chronic anemia on procrit injections
9. Prostate CA on Lupron
10. Gout
Social History:
SOCIAL HISTORY: Lives at a senior facility in [**Location (un) 745**]. Has help
with cleaning, other chores. Denies alcohol and tobacco.
Family History:
Coronary artery disease
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, HR 75, BP 112/55, RR 28, Sao2 97%/4L O2 NC
HEENT: NCAT, PERRL, EOMI, dry mucous membranes, OP clear
Neck: JVP elevated approx 4cm above sternal notch
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Pulm: diffusely decreased BS on R. Bibasilar crackles.
Abd: soft, nontender, nondistended, BS+
Ext: warm and dry, 1+ pitting edema, 1+ bilateral pulses in PT
Neuro: alert and oriented, CN III-XII intact, moves all
extremities (strength not tested)
Pertinent Results:
EKG: NSR at 80bpm, axis in nl quadrant, QRS borderline, q waves
in V1-V3, ST depressions in I, II, aVL, V4-6, STE in V1-3,
biphasic TW in V4-6.
.
CXR [**2134-9-11**]: Interval development of perihilar patchy opacities
consistent with left ventricular heart failure.
CXR 8pm: read pending
.
[**2134-9-12**] Cath
COMMENTS:
1. Right heart catheterization revealed elevated right and left
sided
pressures. (PCWP = 25 mmhg).
2. Left heart catheterization revealed no evidence of systolic
hypertension. Calculated cardiac output and index were 5.0/2.8.
3. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The left main coronary
artery had
a 40% mid-vessel stenosis. The left anterior descending artery
had
diffuse proximal disease with serial 70-80% stenosis. The left
anterior
descending had mild diffuse disease in the mid and distal
segments. The
large first diagonal had an 80% proximal lesion. The left
circumflex
coronary artery had mild diffuse disease in the proximal, mid,
and
distal segments. There was a subtotal occlusion of the OM1.
The right
coronary artery was the dominant vessel. There was total
occlusion of
the right coronary artery in the proximal segment. The distal
RCA
filled via collaterals from the LCA septal branches.
4. No left ventriculography was undertaken given elevated Cr.
5. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a minivision 2.5 X 23 stent of the proximal OM1 with
lesion
reduction from 99 to 0%
6. Successful predilaton using a 2.0 X 20 Maverick balloon and
stenting
using 3.0 X 30 Driver stent of the proximal LAD with lesion
reduction
from 80% to 0%.
7. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a 2.25 X 15 minivision stent of the proximal D1 with
lesion
reduction from 80% to 0%. The final angiogram showed TIMI III
flow in
the vessels intervened with no residual stenoses in any of the
stents.
Thre was no distal embolisation or dissection noted in any
vessel.
8. Successful insertion of IABP via right femoral artery.
( see PTCA comments for the above procdures from 5 through to 8)
9. At the request of the renal consultants, a 12 French Dialysis
central
venous catheter was placed using the Seldinger technique in the
left
common femoral vein.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided pressures.
3. Preserved cardiac output/cardiac index.
4. Successful stenting of the OM, LAD and D1.
5. Successful insertion of IABP via right femoral artery.
6. Successful implantation of a central venous dialysis catheter
in the
left femoral vein.
URINE CULTURE (Final [**2134-9-23**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
>100,000 ORGANISMS/ML..
IDENTIFICATION BEING PERFORMED ON CULT# 196-9912C
[**2134-9-19**] AS
REQUESTED BY DR. [**Last Name (STitle) 9974**] ON [**2134-9-21**]..
Brief Hospital Course:
1. Rhythm: pt had 2 episodes of monomorphic VT accompanied by
fall in BP, LOC, terminated x 1 via precordial thumb.
Electrolytes were repeleted, pt was bolused with Amiodarone x 2,
and started on an Amio gtt. Amiodarone was then changed to po,
with a dosing schedule of 400 mg [**Hospital1 **] for one week, followed by
400 mg daily for one week, then 200 mg per day. Monomorphic VT
thought to be likely due to a fixed area of scarring from
previous MI. Placement of an ICD was discussed. However, given
the pt's poor prognosis for non sudden cardiac death reasons,
and given his increased infectious risk, it was decided to treat
his arrhythmia medically. Of note, the QT interval was
prolonged (506), likely secondary to amiodarone. Patient
remained in sinus rhythm on Amiodarone.
2. CAD: Pt with NSTEMI. Cath on [**9-12**] showed 3 vessel disease,
subsequently underwent successful stenting of OM, D1, LAD and
IABP placement. IABP was discontinued after the patient was able
to maintain his own pressure.
Echo completed on [**9-13**], which showed apical akinesis, with
severely depressed systolic function. Patient was initially
started on heparin and bridged to Coumadin, however, he had
another episode of guaiac positive stool, and given his history
of melena and coffee ground emesis, the risk for GI bleed was
thought to be high and anticoagulation was discontinued.
The patient was continued on an aspirin, Statin, beta blocker,
and was started on an ACE, all of which he will continue as an
outpatient. His swan and sheath were discontinued without
complications.
3.PUMP: CHF: EF 20% by ECHO
He was initially placed on Imdur/Hydral for afterload reduction
and an ACE was initially avoided in an attempt to salvage his
kidneys. However, he was eventually started on low-dose
lisinopril to be titrated up if necessary. Patient also
underwent hemodialysis on Mon/Wed/Fri schedule.
4. Renal: Chronic renal disease, secondary to hypertensive
nephrosclerosis, is status post graft placement with mature A-V
graft. Quentin catheter initially used, then discontinued once
graft accessible. On [**9-22**], graft noted to be difficult to
access per renal, patient underwent AV fistulogram, and
successful angioplasty was performed.
5. ID: Patient completed a seven day course of levofloxacin for
suspected pneumonia, white blood count noted to be persistently
elevated. Patient was pan cultured, and a urine culture was
positive for yeast. Foley catheter was discontinued and a
repeat culture was sent, also positive for [**Female First Name (un) **]. Patient
started on a 2 week course of Fluconazole. Blood cultures
pending at time of discharge, no growth to date.
6. Heme: anemia, likely anemia of chronic disease from chronic
renal disease. Patient also had an episode of melena and coffee
ground emesis, guaiac positive stool. Hematocrit was followed,
and patient was transfused as necessary to keep hematocrit above
30. Patient will need GI workup as an outpatient. Oral iron
supplementation was discontinued as patient receiving Fe in
addition to EPO and Procrit at hemodialysis
7. DM: Patient was started on glargine for persistent
hyperglycemia and covered with a regular insulin sliding scale
with Accu-Check to monitor.
8. Psych: Patient was continued on his home dose of Zoloft 100
mg once daily.
Patient tolerated a low Na/cardiac healthy diet and was placed
on a PPI for GI prophylaxis.
Patient was discharged to rehab facility with plan to follow up
with cardiology and PCP within the next month.
Medications on Admission:
. Nifedipine XL 60 mg daily
2. Calcitriol 0.25 mcg dialy
3. Lisinopril 2.5 mg once daily
4. Aspirin 325 mg once daily
5. Lasix 40 mg once daily
6. Glyburide 10 once daily recently changed to Glipizide
7. Clonidine 0.2mg [**Hospital1 **]
8. Zoloft 100mg daily
9. Simvastatin 40mg daily
10. Tums one tablet TID
11. Procrit injections 16,000 units q. week.
12. Lupron injections at Heme/[**Hospital **] clinic
13. Niferex 150 mg daily (supplemental iron).
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please continue to take twice a day for the next two
days. Please begin taking 400mg once a day on [**9-24**], and
continue for one week. Then please take 200mg once a day.
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Acute Coronary Syndrome
Congestive heart failure
chronic renal disease
urinary tract infection
Discharge Condition:
Good- patient hemodynamically stable and afebrile, heart rate
and rhythm has been well controlled.
Discharge Instructions:
We have started you on a new medication to help control your
heart rhythm, and a new medication to help control your blood
pressure. In addition, we have started you on a medication to
help treat a urinary tract infection. Please take these and all
of your medications as instructed. Please maintain all of your
follow-up appointments. Please return to the hospital if you
develop chest pain, shortness of breath, fevers, or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2134-10-14**] 2:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Known lastname 720**], M.D. Date/Time:[**2134-10-20**] 10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-11-24**] 10:00
You have an appointment scheduled with Dr. [**Last Name (STitle) **] at the [**Hospital 61**] [**Hospital 620**] campus on [**10-7**] at 10am. Please arrive
at 9:45am to register.
ICD9 Codes: 5849, 4280, 5070, 4271, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4668
} | Medical Text: Admission Date: [**2146-4-24**] Discharge Date: [**2146-5-3**]
Date of Birth: [**2146-4-24**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name5 (NamePattern1) **] [**Known lastname 66887**] is the former 2.785-
kg product of a 35 and 5/7 weeks gestation pregnancy born to
a 30-year-old G1/P0 woman.
PRENATAL SCREENS: Blood type O+, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, group beta strep status unknown.
COMPLICATIONS: The pregnancy was complicated by maternal
fibroids and unstoppable preterm labor.
DELIVERY: The infant was born by spontaneous vaginal
delivery with Apgar scores of 8 at one minute and 9 at five
minutes. He received blow-by oxygen in the delivery room
because of persistent cyanosis. He was admitted to the
neonatal intensive care unit for treatment of prematurity and
respiratory distress.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit; weight 2.785 kilograms (50th to 75th
percentile), length 45 cm (50th percentile), head
circumference 31 cm (25th percentile). GENERAL: A
nondysmorphic slightly preterm male with respiratory distress
manifested by grunting, flaring and retractions. HEAD, EARS,
EYES, NOSE, AND THROAT EXAMINATION: Molding of the head,
palate intact, red reflex present bilaterally. NECK: Supple
without masses. SKIN: Pink and ruddy. CHEST: Lungs with
shallow respirations, grunting and intercostal retractions.
CARDIOVASCULAR: A regular rate and rhythm. A grade 1/6
systolic murmur at the left sternal border. Femoral pulses 2+
bilaterally. ABDOMEN: Soft with active bowel sounds. No
masses or distention. GU: Normal male with testes descended
bilaterally. MUSCULOSKELETAL: Clavicles intact. Hips stable.
Spine normal. NEURO: Good tone with normal suck and gag
reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: [**Male First Name (un) **] was placed on continuous positive
airway pressure upon admission to the neonatal intensive
care unit. His maximum oxygen requirement was 35% oxygen.
He was extubated to nasal cannula 02 on day of life #3
and remained on nasal cannula through [**4-30**].He remained in
room air thereafter.
A chest x-ray was consistent with retained fetal lung
fluid.
2. CARDIOVASCULAR: The murmur noted on admission resolved
within 24 hours.
He has maintained normal blood pressures and heart rates.
3. FLUIDS, ELECTROLYTES, NUTRITION: [**Male First Name (un) **] was initially n.p.o.
and treated with intravenous fluids. Enteral feeds were
started on day of life #2 and gradually advanced to full
volume.He is currently on MM20 or E20 and his weight prior
to discharge was 2730 grams.
4. INFECTIOUS DISEASE: Due to respiratory distress and
prematurity, he was evaluated for sepsis. The white blood
cell count was benign. A blood culture was obtained prior
to starting ampicillin and gentamicin. The blood culture
was negativ at 48 hours, and the antibiotics were
discontinued.
5. HEMATOLOGICAL: Hematocrit at birth was 49.2%. He did not
receive any transfusions of blood products.
6. GASTROINTESTINAL: Peak serum bilirubin occurred on day of
life # 5 ; total 14.1 mg/dL over 0.3 mg/dL direct. He was
not treated with phototherapy.His last bilirubin level
was 12.2/0.4 on [**5-1**].
7. NEUROLOGY: [**Male First Name (un) **] has maintained a normal neurological exam
during admission, and there are no neurological concerns
at the time of discharge.
8. SENSORY: Hearing screening passed prior to discharge.
9. CIRCUMCISION:[**5-3**]
10. IMMUNIZATIONS: Hepatitis B given on [**5-1**].
DISCHARGE DISPOSITION: f/u AT [**Hospital **] PEDIATRICS, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**5-3**],VNA to visit home day post discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 and 5/7 weeks gestation.
2. Respiratory distress secondary to retained fetal lung
fluid.
3. Suspicion for sepsis ruled out.
4. Hyperbilirubinemia
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2146-4-28**] 21:01:58
T: [**2146-4-28**] 21:52:41
Job#: [**Job Number 66888**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4669
} | Medical Text: Admission Date: [**2158-6-23**] Discharge Date: [**2158-7-3**]
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 106206**] is an 85 year
old female who had previously undergone cystectomy and
creation of a continent urinary diversion for muscle invasive
grade III out of III, stage 2-3 bladder cancer in [**2145**].
Subsequent to this operation, she developed multiple
postoperative complications including an abscess, requiring
drainage, and a perforation of the continent urinary
reservoir. This was repaired by Dr. [**Last Name (STitle) 519**] from general
surgery. Since that time, she has had a difficult time
following instructions and catheterizing herself. She has
developed numerous large calculi within the continent urinary
reservoir and has been using a suprapubic catheter to manage
these complications over the past few years.
Prior to admission, she had a suprapubic tube which was
severely encrusted and not functional. It has not been able
to be removed from the reservoir. She was admitted to have
her reservoir revised, and had a right percutaneous
nephroureteral stent placed by the interventional radiology
department on [**2158-6-23**].
PHYSICAL EXAMINATION: Physical examination revealed a calm,
pleasant female with a temperature of 98.9; blood pressure of
170/80; pulse of 106; respirations of 20. Her oropharynx was
clear. Her chest was clear to auscultation bilaterally.
Heart demonstrated tachycardia with a regular rhythm. Her
abdomen was soft and nontender. She has an approximately 22
French suprapubic tube going into her reservoir with the
catheter stoma site covered with a bandage. She has a well
healed midline abdominal wound. She appears to be
neurologically intact and is able to converse and follow
directions without difficulty.
On the date of admission, her laboratory studies were as
follows: Her white count was 8.7; hematocrit was 37.9;
platelet count was 251. She had an INR of 1.1.
HOSPITAL COURSE: Ms. [**Known lastname 106206**] was admitted on [**6-23**] to
undergo percutaneous nephroureteral stent placement by the
interventional radiology department. This was unsuccessfully
attempted on the left side but was successful on the right.
On [**2158-6-26**], the patient underwent exploratory
laparotomy, lysis of adhesions, resection of a continent
urinary reservoir, creation of an ileal loop urinary
diversion along with resection of small bowel. The operation
was uneventful without complications and the patient spent a
brief course in the Post Anesthesia Care Unit prior to
transfer to the general medical floor.
On postoperative day number two, it was noted that the
patient, post extubation, had some difficulty with her mental
status. She was, therefore, monitored for a brief period, to
ensure that she did not remove any of her lines.
On postoperative day number four, the patient was resumed on
her psychiatric medications with the expectation that they
might benefit her changes in mental status.
Physical therapy consultation was obtained at this time and
it was determined that the patient would benefit from a short
term rehabilitation course to improve strength and ambulating
without assistance. The patient was discharged on
postoperative day number seven after undergoing an
uncomplicated hospital course. Her condition on discharge is
good. She will be discharged to a short term rehabilitation
facility.
DISCHARGE DIAGNOSES:
Bladder cancer with obstruction.
Major depressive disorder.
Status post ileal loop urinary diversion.
Status post small bowel resection.
Hypovolemia.
DISCHARGE MEDICATIONS:
On discharge, she will be taking Metoprolol 25 mg p.o. twice
a day.
Pantoprazole 40 mg p.o. q. day.
Elanzepine 5 mg p.o. q h.s.
Bupropion 100 mg p.o. twice a day.
Trazodone 25 mg p.o. four times a day prn.
Venlafaxine 75 mg p.o. three times a day.
Doxepin 50 mg p.o. q h.s.
FOLLOW-UP PLANS: Mrs. [**Known lastname 106206**] is to follow-up with Dr.
[**First Name (STitle) **] [**Name (STitle) 4229**] in two weeks for nephroureteral stent removal.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16721**], M.D.
MEDQUIST36
D: [**2158-7-3**] 08:48
T: [**2158-7-3**] 07:57
JOB#: [**Job Number 106207**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4670
} | Medical Text: Admission Date: [**2188-5-30**] Discharge Date: [**2188-6-4**]
Date of Birth: [**2107-7-25**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Burr hole evacuation of SDH
History of Present Illness:
This is a 80 year old Russian speaking male who presents to the
Emergency Department after experiencing dizziness and falling at
home between 9pm on [**2188-5-29**] to 9am [**2188-5-30**] per his son in law
who accompanies the patient. The patient was found at his home
on the floor, incontinent of urine. It is unknown whether there
was a loss of consciousness. He lives alone and his family had
to break down the door to reach him. He denies use of
anticoagulant medication. He stated that he was ambulating to
the bathroom with his walker and fell twice. One time he hit his
head. The patient denied nausea or vomiting, hearing or visual
changes, speech difficulty, weakness, or numbness and tingling.
The patients son in law reports that he fell back in [**2188-3-3**]
at which time he was admitted to [**Hospital3 **] and was
diagnosed with a left Subdural hematoma and was discharged 3
days later without intervention.
Past Medical History:
dm-oral,HTN, hypercho,kidney stones, gallstones, LBP, fatty
liver, anemia, renal insuff, edema, tendinitis, prostatism
Social History:
lives at home alone. next of [**Doctor First Name **] id daughter [**Name (NI) 3968**]
[**Name (NI) 12305**]
Family History:
non contributory
Physical Exam:
On admission:
O: T:98.9 BP:141 /60 HR:102 R:16 O2Sats:99%
Gen: Russian speaking only comfortable, NAD.
HEENT: Pupils:2.5-2 EOMs intact
Neck:hard collar on
Extrem: Warm and well-perfused. left elbow pain on palpation
Neuro:
Mental status: Russian speaking only, Awake and alert,
cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.but patient is
confused as he is stating there is a "metal device" on his left
leg and there is not one.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-7**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
No clonus
rectal tone intact
point tenderness: T 10/L [**4-7**]
Coordination: Dysmetria bilaterally finger-nose-finger, intact
rapid alternating movements.
On discharge:
AOx3, PERRL, EOM intact, face symm, tongue midline. MAE [**5-7**]
except left grasp [**4-7**]. No pronator. Russian speaking. Head
incision C/D/I.
Pertinent Results:
CT head [**2188-5-30**]:
1. Acute-to-subacute on chronic subdural hematomas in the right
frontoparietal and left temporoparietal regions with 6 mm of
right-to-left
midline shift and early subfalcine herniation.
2. No evidence of fracture.
CT C-spine [**2188-5-30**]:
1. No evidence of fracture or malalignment.
2. Severe degenerative changes of the cervical spine with
posterior
osteophytes which places the patient at increased risk for
spinal cord injury.
Pelvis X-ray [**2188-5-30**]
No evidence of acute fracture or dislocation. Ovoid area of
relative lucency along the superior aspect of the left femoral
neck may be
artifactual, although lesion in this area is not excluded. If
pain is
referred to this site, recommend dedicated views of the left
hip.
X-ray shoulder [**5-30**]
1. Suboptimal axillary view for evaluation of dislocation. If
clinical
concern for left shoulder dislocation, recommend repeat axillary
view or Y
view. No evidence of acute fracture.
2. Calcific tendinosis.
X-ray knee [**5-30**]:
1. Suprapatellar joint effusion with question of a small fat
fluid level versus artifact, which raises concern for possible
knee fracture. While no fracture line is identified
radiographically, it is not excluded. Recommend clinical
correlation and consider CT.
CT Head [**5-31**]:
1. Decreased shift of midline structures, status post right
subdural hematoma drainage with catheter in situ, in the
subdural compartment overlying the right cerebral convexity.
2. Stable left temporoparieto-occipital subdural hematoma, with
maximal
thickness of 9 mm.
CT head [**6-1**]:
Interval right drainage catheter removal with slight decrease in
size of right pneumocephalus and subdural hematoma. Stable left
parietal occipital subdural hematoma.
Carotid Series [**2188-6-3**]:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right there is no plaque in the ICA. On the left there is no
plaque seen
in the ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 53/11, 61/20, 55/17 cm/sec. CCA peak
systolic
velocity is 78 cm/sec. ECA peak systolic velocity is 79 cm/sec.
The ICA/CCA
ratio is .8. These findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 53/13, 57/19, 47/14 cm/sec. CCA peak
systolic velocity
is 104 cm/sec. ECA peak systolic velocity is 104 cm/sec. The
ICA/CCA ratio is
.5. These findings are consistent with no stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA no stenosis.
Left ICA no stenosis.
ECHO & EEG [**Location (un) 1131**] still pending.
Brief Hospital Course:
Mr. [**Known lastname 12306**] was admitted to [**Hospital1 18**] on [**2188-5-30**]. He was seen by the
trauma team and cleared of acute injuries. He was taken to the
OR with Dr. [**Last Name (STitle) 739**] and a subdural drain was palce. He was
monitored in the ICU. On [**5-31**] the subdural drain was
discontinued. He was neurologically stable and was transfered to
the floor. On
5.30 his C-spine was cleared. A syncope workup was in place and
completed. He was screened by PT/OT who felt patient needed
acute rehab. On [**2188-6-4**] he was discharged to the [**Location (un) 583**]
House.
Medications on Admission:
Glyburide 5 mg tid, Lipitor 40 mg
qd,atenolol, atorvastatin, citalopram, clonazepam, Glyburide,
ketoconazole, lisinopril, metformin, Nasonex, Actos, Colace
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Right SDH
Left SDH
Suprapatellar joint effusion
Left shoulder Calcific tendinosis
DDD C-spine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-12**] days for removal of your
staples or sutures. You may also have them removed at rehab.
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in [**4-8**] weeks.
??????You will need CT of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2188-6-4**]
ICD9 Codes: 2859, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4671
} | Medical Text: Admission Date: [**2126-8-1**] Discharge Date: [**2126-8-10**]
Date of Birth: [**2058-8-5**] Sex: F
Service:
CONTINUATION:
HOSPITAL COURSE: The patient was taken to the Surgical
Intensive Care Unit after operation for fluid management. In
brief, the patient's postoperative course was essentially
unremarkable. A Swan catheter was in on postoperative day
one to gage her fluid status and measuring cardiac output.
She remained intubated until postoperative day number five
and she was aggressively hydrated postoperative day one for
low urine output and her blood pressure was controlled by
Nitroglycerin intravenous drip and she was started on beta
blocker, Lopressor 10 mg q6hours. She is empirically started
on a five day course of Levofloxacin and Flagyl for
prophylactic treatment. From postoperative day three, she is
started on some Lasix to help mobilize fluid and she
responded to the diuretic effectively. She is essentially
negative for two liters every day from postoperative day
number three and, by postoperative day number five, she is
tolerating well mechanical ventilation. She is successfully
extubated on that day. After extubation, the patient
remained in the Intensive Care Unit for two more days.
During that time, she was agitated and self discontinued her
own central line and attempt was made to replace central
venous catheter which failed and she was successfully placed
with a small bore intravenous for peripheral fluids and
peripheral intravenous antibiotics. She is then started on
regular diet for which she tolerated well with good ostomy
output. She was transferred to the floor on [**2126-8-8**],
postoperative day number seven, and remained afebrile with
good blood pressure control. She had a minimal amount of
pain and was on two liters of oxygen with nasal cannula. She
receives aggressive pulmonary therapy and was ambulating with
assistance of physical therapy. She is making a good amount
of urine every day and is discharged to rehabilitation
facility for further physical rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 15 mg p.o. once daily.
2. Metoprolol 100 mg p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Albuterol inhaler as needed.
DISCHARGE DIAGNOSIS: Sigmoid diverticulitis.
CONDITION ON DISCHARGE: Stable.
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2126-8-10**] 11:27
T: [**2126-8-10**] 12:13
JOB#: [**Job Number 52305**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4672
} | Medical Text: Admission Date: [**2125-5-28**] Discharge Date: [**2125-6-1**]
Date of Birth: [**2045-6-5**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Heparin Agents
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Femur Fracture, Fall
Major Surgical or Invasive Procedure:
Femur repair
Midline placement
History of Present Illness:
79 year old Female who presents with femoral trochanteric
fracture after sustaining a fall in the bathroom. She states she
was cleaning her bathroom when she is unsure exactly what
happened, but she fell after getting her walker. Her husband
found her, and believes she fell over a cleaning bottle with her
walker. The patient denies fainting or loss of consciousness.
Her husband called EMS where plain film [**Name (NI) 108380**] revealed left
intertrochanteric femur fracture. Ortho-Trauma was consulted and
recommended operative repair. In addition, cervical spine films
were concerning for cervical vertebral subluxation, so the
patient was placed in a Cervical Hard-Collar pending orthospine
clearance.
Of note the patient was recently admitted here at [**Hospital1 18**] for
workup of cryptogenic cirrhosis with a significant variceal
bleed, requiring ICU admission with Dr. [**Last Name (STitle) **].
Past Medical History:
Lower GIB [**2123-12-13**] - colonoscopy with diverticulosis and
angioectasias
Diabetes Type 2 - on insulin (last A1C unknown)
Atrial fibrillation
CAD s/p stent to RCA in [**2104**] and 2 bare metal stents to the LCx
on [**2123-11-23**]
Acute and Chronic Diastolic CHF (EF per records preserved but no
records in our system)
Benign Hypertension
Pulmonary Hypertension
Dyslipidemia
Hypothyroidism (s/p thyroidectomy)
Breast CA s/p b/l mastectomies and tamoxifen (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**])
s/p breast reconstruction
COPD
Thrombocytopenia
Recent ICU admission [**10/2123**] at OSH with staph aureus bacteremia
Infected 3rd left toe [**10/2123**]
.
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108377**]
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4768**] [**Last Name (NamePattern1) 5456**]
Social History:
Social history is significant for the absence of current tobacco
use; she quit smoking in [**2106**]. There is no history of alcohol
abuse. Patient lives with her husband; she used to work in a
candy factory. She currently uses a walker and has home PT and
[**Year (4 digits) 269**].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: + Myalgia, + Arthralgia (hip), - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.1, 90/40, 77, 18, 94%
GEN: NAD
Pain: 0/10
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: Trace LE Edema, Externally rotated Left leg, moderate
echymosis Left knee
DERM: CVS changes
NEURO: CAOx1, Non-Focal ,CN II-XII intact, - Asterixis
VASC: DP Pulses 1+ B/L
Pertinent Results:
[**2125-5-29**] 06:20AM BLOOD WBC-6.7 RBC-3.15* Hgb-10.1* Hct-30.3*
MCV-96 MCH-32.1* MCHC-33.5 RDW-17.3* Plt Ct-76*
[**2125-5-28**] 01:50PM BLOOD WBC-9.2# RBC-3.49* Hgb-10.7* Hct-32.3*
MCV-93 MCH-30.7 MCHC-33.1 RDW-16.8* Plt Ct-98*
[**2125-5-29**] 06:20AM BLOOD PT-13.5* PTT-29.2 INR(PT)-1.2*
[**2125-5-29**] 06:20AM BLOOD Glucose-89 UreaN-37* Creat-2.2* Na-134
K-4.5 Cl-97 HCO3-24 AnGap-18
[**2125-5-29**] 06:20AM BLOOD CK(CPK)-33
[**2125-5-28**] 01:50PM BLOOD CK(CPK)-57
[**2125-5-29**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2125-5-28**] 01:50PM BLOOD cTropnT-0.04*
[**2125-5-29**] 06:20AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8
[**2125-5-28**] 03:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2125-5-28**] 03:30PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-MOD
[**2125-5-28**] 03:30PM URINE RBC-[**3-22**]* WBC->50 Bacteri-MANY Yeast-MANY
Epi-0-2 TransE-0-2
CT C-SPINE W/O CONTRAST Study Date of [**2125-5-28**] 1:37 PM
IMPRESSION:
1. No acute fracture or prevertebral soft tissue swelling.
2. Anterolisthesis at C6-C7 is of unknown chronicity in the lack
of prior
comparisons, though likely degenerative given presence of
additional extensive degenerative change. If there is high
concern for ligamentous injury, an MRI may be performed for
further characterization.
3. Extensive cervical spondylosis, as described above, causing
multilevel
neural foraminal narrowing and moderate canal stenosis from C3
through C5,
which predisposes the patient to cord injury. MRI should be
considered for
further evaluation of cord injury if clinically indicated.
4. Right pleural effusion.
CT HEAD W/O CONTRAST Study Date of [**2125-5-28**] 1:37 PM
IMPRESSION: No acute intracranial process.
Final Attending Comment:
There is a small hyperdense focus( 2:13) in the right frontal
lobe which could represent a small acute bleed versus
calcification.There is no significant edema. Findings conveyed
to the clinical team.
KNEE (AP, LAT & OBLIQUE) LEFT Study Date of [**2125-5-28**] 2:12 PM
Intertrochanteric fracture of left proximal femur. Findings
conveyed to the referring physician via [**Name9 (PRE) **].
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) Study Date of [**2125-5-28**]
2:12 PM
IMPRESSION:
Intertrochanteric fracture of left proximal femur. Findings
conveyed to the referring physician via [**Name9 (PRE) **].
CHEST (PRE-OP AP ONLY) Study Date of [**2125-5-28**] 2:12 PM
IMPRESSION:
1. Significant interval decrease in right-sided pleural effusion
which is now small. No left pleural effusion.
2. Lucency at the right lung base may be related to loculated
fluid, however, basilar pneumothorax cannot be excluded.
Recommend followup radiograph for further evaluation.
3. Stable cardiomegaly and prominent main pulmonary artery
suggestive of
pulmonary hypertension.
CHEST (SINGLE VIEW) Study Date of [**2125-5-28**] 6:42 PM
FINDINGS: In comparison with the earlier study of this date, the
degree of
blunting of the right costophrenic angle consistent with a small
right
effusion is unchanged. Lucency at the right lung base again is
suggestive of basilar pneumothorax. Progressive followup of this
area is again suggested. Stable cardiomegaly with prominence of
the central pulmonary arteries consistent with pulmonary
arterial hypertension. Central catheter position is unchanged.
Brief Hospital Course:
1. Intratrochanteric Femoral Fracture due to Fall in Bathroom
Patient was evaluated by orthopedics in the ED and was
scheduled for femur repair in OR. She was dialyzed first then
sent to the OR. She underwent successful repair of her femur and
post-op had a short stay in the ICU for hypotension but then was
transferred to the floor without further complications. Patient
required DVT prophylaxis after surgery however she was unable to
receive heparin products given her history of HIT and could not
be on fondaparinux given her renal disease so was started on
argatroban gtt and bridged to coumadin. she should continued
coumadin for ONLY ONE MONTH and then it should be discontinued.
Given her increased risk of GIB and fall risk coumadin is not a
good long term drug for her.
2. PREOPERATIVE CARDIAC ASSESSMENT : Patient was deemed to be at
moderate risk by ESRD, CHF (Diastolic) which is compensated,
Diabetes, Atrial Fibrillation for a intermediate risk procedure
(ORIF). Patient was already beta-blocked with Nadolol. Patient
is a type 2 diabetic, so could be off insulin during operation,
however good glucose control post-operative was important for
wound healing. Patient has a history of COPD, so used a
prolonged I:E ratio to prevent air trapping.
3. Chronic Diastolic CHF - Chronic. Remained euvolemic
throughout hospital course.
4. Bacterial UTI. Patient had positive UA on admission and h/o
Klebsiella UTI in past that was sensitive to Cipro. She was
started on ciprofloxacin [**2125-5-28**] and completed a 5-day course.
5. Pre-Existing Diabetic Heel Ulcer. Wound care consult
obtained. Wound dressed appropriately. Should continue dressing
per wound care recommendations.
6. Dementia, Acute Delerium. Patient appeared demented without
diagnosis in the past, and as such there was the concern of an
acute delerium as the precipitant of the fall. The UTI could be
a preciptant as well. Geriatric consultation obtained. MSSE
performed and scored 17. Geriatrics suggested outpatient
initiation of donepezil for alzheimers/vascular dementia and
this will be initiated by her PCP.
7. Cryptogenic Liver Cirrhosis, Esophageal Varices: Medications
were hepatically dosed.
8. ESRD: Medications were renally dosed. Patient continued on HD
Tues/Thurs/Sat.
9. Type 2 Diabetes Uncontrolled with Complications. Controlled
with RISS
10. Benign Hypertension
- Patient has a history of benign hypertension, but for the last
2 months has been intermittantly hypotensive, likely due to
liver disease. BP was monitored carefully. Nadolol was held when
necessary. No longer on any other anti-hypertensives.
Patient is Full Code, confirmed with husband
Medications on Admission:
Prilosec 20mg daily
Nadolol 20mg daily if BP>100 and not on dialysis days
Synthroid 75mg daily
Lipitor 20mg daily
Acidophilus am and pm
Folic Acid 800mg QAM
Novolin sliding scale
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Insulin Lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous
ASDIR (AS DIRECTED).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6
hours) as needed for pain.
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM for 30 days.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Outpatient Lab Work
Please draw INR 2 days after discharge and fax to physician at
the facility and have him dose the coumadin appropriately. Goal
is INR [**2-20**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Femur Fracture
UTI
ESRD on HD
Discharge Condition:
The patient was afebrile and hemodynamically stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted to the hospital with a broken hip. You had
surgery to fix this. You also had a urinary tract infection. You
were treated with antibiotics for this.
Medication Changes:
START: Coumadin 3mg daily for THIRTY DAYS
Please come back to the hospital or call your doctor if you have
fevers, chills, shortness of breath, palpitations, chest pain,
abdominal pain, nausea, vomiting, pain with urinating, pain in
your leg, dizziness, or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1521**] [**Last Name (NamePattern1) 1522**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2422**]
Date/Time:[**2125-7-9**] 11:50
Please follow up with your primary care doctor in [**2-21**] weeks.
Completed by:[**2125-6-1**]
ICD9 Codes: 5856, 5990, 2930, 5715, 4280, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4673
} | Medical Text: Admission Date: [**2178-8-21**] Discharge Date: [**2178-8-28**]
Date of Birth: [**2101-8-30**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / Penicillins
Attending:[**Doctor First Name 3290**]
Chief Complaint:
nose bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness:
76yo F w/ PMHx of CAD, HTN, T2DM, CKD, and HLD who presents from
OSH with brisk epitaxis and evaluation for embolization.
History provided through Spanish speaker. Patient reports that
her blood nose started on the Tuesday prior to admission around
noon time. She reports that it started spontaneously. She denies
a history of trauma, recent instrumentation of the nose, or any
recent medication changes. She denies taking or starting
warfarin. She reports a large amount of blood at that time
coming from the front of her nose as well as from her mouth. She
went to the [**Hospital3 **] ED where she underwent packing and was
discharged with an outpatient follow-up appointment with ENT.
THe patient went to [**Hospital1 487**] Family Health Center Clinic
[**2178-8-20**] vai EMS because she had a repeat nose bleed. Reportedly
she was in the waiting room spitting up blood and she was sent
to the ED for further evaluation. In the ED at the OSH, the
patient was noted to have bleeding from both nares. She was seen
by ENT at OSH who packed her nose, presumably on the right. She
was admitted to the ICU for serial HCTs and monitoring given her
history of CAD.
The patient reports dizziness, lightheadedness and weakness. She
also reports nausea when the bleeding started. She has never had
epitaxis in the past and reports that she has never had any
difficulty with prolonged bleeding. She reports that when she
was having menstrual cycles, 3 days would be heavy and then her
blood flow would lighten up over 2 days. She has never been told
that she has been an easy bleeder during procedures, but she
reports that her only major surgery has been cataract surgery
repair.
On arrival to the MICU, the patient reports feeling weak and she
complains of [**8-25**] right facial pain.
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:
-CAD s/p stent placement
-HTN
-HLD
-T2DM on insulin; HgbA1C 9.7 [**5-/2178**]
-CKD with baseline serum creatinine 1.36
-OA
-Anxiety
-s/p cataract surgery in [**2169**] b/l; no other surgical procedures
Social History:
Lives at home. Quit smoking in [**2160**]. Occassional EtOH use- 1
glass of wine; no illicit drug use
Family History:
No history of bleeding disorders.
Physical Exam:
ADMISSION:
Vitals: T:98.7 BP:138/52 P:76 R:18 O2:97%ra
General: NAD
HEENT: nasal packing right nostril, no facial trauma, sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mild rales bibasilarly, improved with cough
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3
DISCHARGE:
Vitals: T:98.9 (98.9) BP:116/50 P:71 R:18 O2:100%ra (additional
humalog = 6)
General: NAD
HEENT: MMM, oropharynx clear, periorbital erythema resolved,
resolved peri-orbital edema, less TTP over right peri-orbital
area as compared to yesterday
Neck: supple, no JVD
Lungs: CTAB
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3
Pertinent Results:
ADMISSION:
[**2178-8-21**] 06:25AM BLOOD WBC-8.4 RBC-3.16* Hgb-8.8* Hct-26.8*
MCV-85 MCH-27.7 MCHC-32.8 RDW-14.6 Plt Ct-162
[**2178-8-21**] 06:25AM BLOOD Plt Ct-162
[**2178-8-21**] 06:25AM BLOOD PT-10.9 PTT-19.0* INR(PT)-1.0
[**2178-8-21**] 06:25AM BLOOD Glucose-332* UreaN-36* Creat-1.1 Na-142
K-4.5 Cl-111* HCO3-22 AnGap-14
[**2178-8-21**] 06:25AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
[**2178-8-21**] 6:29 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2178-8-23**]**
MRSA SCREEN (Final [**2178-8-23**]): No MRSA isolated.
OTHER:
[**2178-8-25**] 1:12 pm ASPIRATE Source: Sinus.
**FINAL REPORT [**2178-8-27**]**
GRAM STAIN (Final [**2178-8-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2178-8-27**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
URINE CULTURE (Final [**2178-8-25**]): NO GROWTH.
[**2178-8-23**] 08:44PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003
[**2178-8-23**] 03:43PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2178-8-23**] 08:44PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-8-23**] 03:43PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2178-8-23**] 03:43PM URINE RBC-0 WBC-62* Bacteri-FEW Yeast-NONE
Epi-5 TransE-<1
[**2178-8-23**] 03:43PM URINE CastHy-1*
DISCHARGE:
[**2178-8-27**] 06:10AM BLOOD WBC-8.7 RBC-3.19* Hgb-8.8* Hct-27.4*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.7* Plt Ct-338
[**2178-8-27**] 06:10AM BLOOD Plt Ct-338
[**2178-8-27**] 06:10AM BLOOD Glucose-88 UreaN-12 Creat-1.1 Na-142
K-4.1 Cl-108 HCO3-25 AnGap-13
Brief Hospital Course:
76F w h/o CAD, HTN, T2DM, CKD, and HLD who presented from OSH
with brisk epistaxis, was ruled out for IR embolization, and was
treated with nasal packing, which was pulled without epistaxis
>72h at time of discharge, and who was treated with antibiotics
for sinusitis/peri-orbital cellulitis.
ACTIVE ISSUES:
# Epistaxis: Patient presented from OSH with nasal packing in R
nare, having received 2u pRBCs. Packing was kept in place for 5
days with azithromycin prophylaxis transitioned to levaquin on
day 4 due to concern for UTI in setting of 1x temperature to
100.6 and pyuria on UA. Patient received 1u additional pRBCs as
Hct<25. ENT was consulted secondary to sinusitis/pre-septal
cellulitis as detailed below, evaluated patient, and removed
additional absorbable packing. Patient was treated with afrin 3x
tid for three days after packing was pulled and received gentle
nasal lavage as per ENT reccommendations to help with patient's
sense of congestion. Hct remained stable at 25. There were no
re-bleeding events. Patient was discharged with hct=27.4
(stable) and instructions to follow-up with PCP.
# Sinusitis/pre-septal cellulitis: Patient developed 1x
temperature = 100.6 on day 5 of having nasal packing. Patient
was hemodynamically stable and on prophylactic azithromycin;
concern for toxic shock was low. CXR was negative and UA showed
pyuria in setting of recent urinary catheter. Patient was
initiated on levofloxacin. Patient developed mild edema in right
peri-orbit, erythema below right eye, and tenderness around
right ear and TMJ. Exam of ear was equivocal. CT was obtained
which showed mucosal thickening in the ethmoid and sphenoid
sinuses. ENT examined patient and removed additional absorbable
packing. Culture of middle meatus showed GPCs. In consultation
with ENT, patient was treated for sinusitis and pre-septal
cellulitis with broad spectrum antibiotics (levaquin +
vancomycin). Cultures speciated normal respiratory flora and
yeast. Patient was afebrile >48h with symptoms (headache,
congestion, peri-orbital edema/erythema) improved at time of
discharge. Repeat imaging is only warranted with symptom
worsening. Patient was transitioned to po antibiotics
(levofloxacin + bactrim). Patient was discharged on day 5 of
broad spectrum treatment for planned 14 day course.
CHRONIC ISSUES:
# CAD: The patient had no acute ST segment changes on EKG on
arrival, and EKG was c/w prior EKGs done at OSH. Patient did not
complain of anginal symptoms. Plavix and ASA were held in
context of bleeding. ASA was restarted secondary to patient's
stent, but plavix was held as there is no indication for plavix,
based on timing of stent placement. Patient was instructed to
follow-up with her cardiologist.
# HTN: In context of epistaxis, tight blood pressure control was
maintained with hydralazine in the ICU upon initial
presentation. Blood pressure medications (amlodipine,
metoprolol) were continued to maintain tight blood pressure
control and aliskiren restarted after ICU course. Lasix was held
throughout admission, and patient was instructed to f/u PCP
[**Name9 (PRE) 111950**] restart. Patient was discharged on home regimen.
# T2DM: Patient insulin dependent as an outpatient, also using
metformin 500mg daily. Patient was maintained on home regimen
with metoformin restarted after ICU stay. Insulin was adjusted
as per blood glucose levels. Blood glucose <180 was achieved
with home regimen. Patient was discharged on home regimen.
# CKD: Patient with baseline Cr 1.38; OSH creatinine 1.39. CKD
is believed to be contributing to patient's anemia. Inpatient Cr
hovered around 1.1-1.2.
# HLD: Remained stable during hospitalization. Continued and
discharged on home
atorvastatin.
# Anxiety: Remained stable during hospitalization. Continued and
discharged on home clonazepam.
TRANSITIONAL ISSUES:
Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient clinic.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aliskiren 150 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Glargine 25 Units Breakfast
Humalog 10 Units Dinner
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Nitroglycerin SL 0.4 mg SL PRN angina
9. Atorvastatin 80 mg PO DAILY
10. Clonazepam 0.5 mg PO BID:PRN anxiety
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aliskiren 150 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Glargine 25 Units Breakfast
Humalog 10 Units Dinner
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Nitroglycerin SL 0.4 mg SL PRN angina
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Atorvastatin 80 mg PO DAILY
9. Clonazepam 0.5 mg PO BID:PRN anxiety
10. Omeprazole 20 mg PO DAILY
11. Aspirin 81 mg PO DAILY
RX *Aspirin Low-Strength 81 mg 1 tablet(s) by mouth once a day
Disp #*100 Tablet Refills:*0
12. Levofloxacin 250 mg PO Q24H
RX *Levaquin 250 mg 1 tablet(s) by mouth once a day Disp #*9
Tablet Refills:*0
13. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *Bactrim DS 800 mg-160 mg 2 tablet(s) by mouth twice a day
Disp #*36 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Epistaxis
Sinusitis / Periorbital cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of a nose bleed.
Your bleeding stopped once we put packing in your nose. The has
now been taken out without any more bleeding.
While you were here, you also developed an infection in your
sinuses and around your eye. You were seen by the nose
specialists and treated with antibiotics.
You are now ready for discharge
We made the following changes to your medications:
- STARTED bactrim (take until [**2178-9-7**])
- STARTED levofloxacin (take until [**2178-9-7**])
- STOPPED plavix
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. D??????az,
Ha sido un placer cuidar de que en el [**Hospital1 827**]. Usted fue admitido a causa de una hemorragia
nasal.
El sangrado se detuvo una vez que ponemos el embalaje en [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]. El ahora ha sido retirado sin sangrado m??????s.
Mientras que usted estuviera aqu??????, que tambi??????n desarroll?????? una
infecci??????n en [**Location 111951**] [**Location 111952**] y alrededor [**Doctor First Name **] ojo. Usted fue
visto por [**Location 111953**] en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] y se trata con
antibi??????ticos.
Ahora est?????? listo para [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 34747**].
Hemos hecho [**Location 33767**] [**Location 111954**] en sus medicamentos:
- EMPEZAR bactrim (tomar hasta 23/07/[**2178**])
- EMPEZAR levofloxacina (tomar hasta 23/07/[**2178**])
- DESCATALOGADO Plavix
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L
Specialty: Primary Care
Location: GREATER [**Hospital1 **] FAMILY HEALTH CTR
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 63099**]
When: [**9-8**] at 11:20am
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2178-9-16**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Completed by:[**2178-8-28**]
ICD9 Codes: 2851, 5859, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4674
} | Medical Text: Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-16**]
Date of Birth: [**2104-10-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
General Anesthesia / phenobarbital / Pentobarbital
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea and Chest pain
Major Surgical or Invasive Procedure:
[**2150-11-12**]: Coronary artery bypass grafting x3: Left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the first marginal branch and diagonal
branch.
History of Present Illness:
46 year old male with type 1 diabetes on an insulin pump,
hypertension, and hypercholesterolemia, with admission to [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**11-2**] with chest pain and mild dyspnea. The chest
pain initially started on Sunday radiating across chest and
under axilla. This persisted all night and by Monday it was
radiating to his left collar bone and down left arm with left
5th digit numbness.
Ruled out for MI. Gated study revealed LVEF of 41% with global
hypokinesis with no areas of ischemia or infarct. It was
initially thought that his CP was non-cardiac and he was sent
home on percocet, but when he tried to return to work, he became
very short of breath and diaphoretic. He then contact[**Name (NI) **] her
primary MD who sent him to see Dr. [**Last Name (STitle) 77919**]. He was sent to
the [**Hospital1 **] where he had a cardiac cath that showed multivessel
disease and was referred for surgical evaluation
However, he and his wife have been anxious at home and over the
past day, he notes slightly more dyspnea at rest. He also has
had continuous CP since his d/c. He contact[**Name (NI) **] cardiac surgery
who asked that he come to the ED.
In the ED, his HR and bp were well controlled, and his pain
improved from [**5-15**] to [**3-15**] with SL nitro. He was still slightly
dyspneic at rest.
Denies PND, edema, leg swelling, h/o DVTs or PEs. ROS otw neg in
detail.
Past Medical History:
Type I DM diagnosed on [**2140-8-16**], on insulin pump
HTN
Hypercholesterolemia
Seizure as a child in the setting of fevers only
Past Surgical History
S/p Lap Cholecystectomy [**2148**]
Social History:
He is married and lives with his wife in [**Name (NI) 20935**] MA.
He has four children ages [**9-25**].
He works full time as an operator at sewage treatment center.
Denied any tobacco and alcohol
Family History:
Father with CABG at age 58.
Paternal grandfather died of MI at age 52.
Maternal grandfather died of HF at age 79.
Maternal uncle died of Ventricular Fibrillation at age 49.
Another maternal uncle died during valve replacement surgery in
his mid 50's.
Physical Exam:
Physical Exam
Pulse: 67 Resp:18 O2 sat:100
B/P Right:107/60 Left:
Height:5 feet 9.5 inches Weight: 201 pounds
General:
Skin: Dry and intact
HEENT: PERRLA, EOMI.
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally
Heart: JVP < 5 cm. PMI focal. Nl S1, S2. No S4. No m.
Abdomen: Soft, non-distended and non-tender.
Extremities:No edema. Warm and well perfused.
Neuro: Grossly intact
Psych: Anxious but otherwise appropriate
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Pertinent Results:
[**2150-11-10**]; CTA CHEST: The aorta is normal in caliber without
acute pathology. The pulmonary arterial tree is well opacified
to the subsegmental level, demonstrating no filling defects to
suggest pulmonary embolism. The heart is normal in size without
pericardial effusion. Multivessel coronary arterial
calcifications are present. There is no mediastinal, hilar, or
axillary adenopathy by size criteria.
The lungs are clear with the exception of bibasilar dependent
atelectasis. Central airways are patent.
BONE WINDOW: No focal concerning lesion.
Limited subdiaphragmatic evaluation demonstrates a 12-mm
interpolar exophytic left renal cyst. The spleen is mildly
enlarged to 14 cm.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Borderline splenomegaly to 13-14 cm, clinical significance
unclear.
[**2150-11-15**] 05:49AM BLOOD WBC-6.6 RBC-3.32* Hgb-9.8* Hct-28.1*
MCV-85 MCH-29.5 MCHC-34.8 RDW-12.4 Plt Ct-132*
[**2150-11-14**] 05:06AM BLOOD WBC-6.7 RBC-3.40* Hgb-10.0* Hct-27.8*
MCV-82 MCH-29.3 MCHC-35.8* RDW-12.2 Plt Ct-125*
[**2150-11-15**] 05:49AM BLOOD Glucose-173* UreaN-14 Creat-1.1 Na-136
K-4.0 Cl-101 HCO3-31 AnGap-8
[**2150-11-14**] 03:00PM BLOOD Glucose-237* UreaN-19 Creat-1.2 Na-135
K-4.0 Cl-100 HCO3-30 AnGap-9
[**2150-11-14**] 05:06AM BLOOD Glucose-123* UreaN-20 Creat-1.3* Na-133
K-4.4 Cl-101 HCO3-28 AnGap-8
Brief Hospital Course:
Mr. [**Known lastname **] is a 46 year-old male with type I DM with left main
equivalent CAD was admitted with acute chest pain and and marked
dyspnea at rest. His chest pain was somewhat atypical given his
essentially normal EKG and prev neg troponins however given his
coronary anatomy and improvement of his chest pain and dyspnea
on Nitro he was admitted to the MICU for presumed subendocardial
ischemia. He was followed by [**Hospital **] Clinic for his type I
Diabetes and insulin pump. On [**2150-11-12**] he was taken to the
operating room with cardiac surgery for Coronary Artery Bypass
Graft surgery. See operative report for further details.
Overall the he tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. He was extubated on post operative
night, alert, oriented and breathing comfortably. The patient
was neurologically intact and hemodynamically stable, weaned
from inotropic and vasopressor support on POD 1. Beta blocker
was initiated and the patient was gently diuresed toward the
preoperative weight. His insulin pump was restarted which he
managed himself. He transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD four he was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The he was discharged home with services in good condition with
appropriate follow up instructions
Medications on Admission:
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - insulin pump 12 0.925 units per hour, 3am
1.4
unit hr, 5am 0.65 units, 7a 0.6 units her hour, 12pm 0.4 units
per hour, 6pm 0.65 units per, 8pm 0.8 units her hour.
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
(One) Tablet(s) by mouth once a day
OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-325 mg Tablet - 1 Tablet(s) by mouth every four hours as
needed for chest pain
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
8. 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*
9. insulin pump
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Diabetes Mellitus Type I on insulin pump
Hypertension
Hypercholesterolemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet
Sternal Incision - healing well, no erythema or drainage
Left leg EVH no erythema or drainage
Edema +1 bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please follow up with outpatient endocrinology for blood glucose
management goal 100-130
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Tuesday [**11-24**] at 10:30 am
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2150-12-16**] 1:00
Location: [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 92599**] [**Telephone/Fax (1) 65733**] - Wednesday [**12-23**]
at 2pm
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) 1661**] [**Telephone/Fax (1) 79522**] in [**3-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2150-11-16**]
ICD9 Codes: 4111, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4675
} | Medical Text: Admission Date: [**2151-3-19**] Discharge Date: [**2151-4-23**]
Date of Birth: [**2095-1-27**] Sex: F
Service:
ADMITTING DIAGNOSIS: Gastric cancer.
HISTORY OF PRESENT ILLNESS: This patient is a 56 year old
female who is diagnosed with a gastric mass by computerized
tomography scan that was performed on [**2151-2-18**]. This
mass was highly suspicious for an infiltrative neoplasm of
the fundus and body of the stomach/linitis plastica.
Endoscopy was then performed, which revealed a gastric mass
involving the gastric cardia, fundus and body and entering
into the distal esophagus just above the esophagogastric
junction. Biopsies were performed and this demonstrated
poorly differentiated adenocarcinoma with a component of
signet ring cells. She presents to the [**Hospital6 649**] for resection of her stomach and placement of
a feeding jejunostomy by Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Polycystic kidney disease.
3. Chronic renal insufficiency.
4. Lower mandible resection for malocclusion at age 18.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q. day.
2. Nexium 20 mg q. day.
3. Norvasc 5 mg q. day.
ALLERGIES: Penicillin.
HOSPITAL COURSE: The patient was admitted on [**2151-3-18**]
and underwent a total gastrectomy with feeding jejunostomy
performed by Dr. [**Last Name (STitle) **]. The patient tolerated the
procedure well. There were no immediate postoperative
complications. Please the operative note for further
details. Her pain was well controlled with an epidural, and
the patient had an nasogastric tube that was placed to
continuous level of suction. On postoperative day #2, the
patient's tube feeds were started at 1/2 strength at 20
cc/hr. On postoperative day #4, the patient was doing well
in the usual postoperative course. An upper gastrointestinal
series was performed, which demonstrated a patent
gastrointestinal tract with no leakage. The patient had some
episodes of vomiting that evening. Because of the upper
gastrointestinal results from earlier that day, it was
believed that her nausea and vomiting was due to
postoperative ileus. Her tube feeds were held but her
epidural was discontinued. Dr. [**Last Name (STitle) 27538**] would also stop
by to see the patient and wrote that he would follow up with
the final pathology results and have the patient follow up as
an outpatient following her discharge for further evaluation
or adjuvant chemoradiation. The patient continues to have
nausea and vomiting and progressively is having increasing
abdominal pain and on [**2151-3-26**], the patient began to
appear ill. A small bowel perforation was suspected, and a
Foley catheter was placed, intravenous fluids were initiated,
broad spectrum antibiotics were started and the patient was
planned to go to the Operating Room for exploration.
In the Operating Room, it was found that there was a kink
distal to the gastrojejunostomy which resulted in perforation
of the gastrojejunostomy. The jejunostomy was repaired
during this operation. Following the operation, the patient
appeared to develop a septic picture. The patient was
continued with volume resuscitation, serial arterial blood
gases were obtained, and a chest x-ray was performed. Later
that evening, the patient developed respiratory distress with
tachypnea and shallow breathing and shortness of breath. The
patient was reinstated successfully. Her arterial blood
gases following sedation was 7.35, 31, 90, 18, and -7. She
was transferred to the Surgery Intensive Care Unit for
further care. She was given 1 unit of blood for a hematocrit
of 22.8. She was continued on Levofloxacin and Flagyl.
Aggressive fluid resuscitation was required for a hypotensive
episode. She was started on Levophed and given albumin to
help with her low blood pressure. She also developed a
reaction to heparin, with decrease in platelet count down to
49 from 93. She became positive for heparin-induced
thrombocytopenia. Fluconazole was also added for further
broad-spectrum coverage. Her tube feeds were also restarted,
and nutrition made recommendations for appropriate tube
feeds. Because of her heparin-induced thrombocytopenia, the
patient was started on Coumadin. As her blood pressures
improved or remained stable, the patient was begun with Lasix
diuresis. Meanwhile, her white count started to climb from
14 to 23.8 on [**2151-4-2**]. A repeat abdominal
computerized tomography scan showed persistent dilated loops
of small bowel that was performed on [**2151-4-4**]. On
[**2151-4-4**], the patient went down for a second
exploratory laparotomy. A takedown of the jejunostomy and
replacement of the jejunostomy tube was performed as well as
lysis of adhesions. There was no apparent perforation. She
was then again transferred to the Surgery Intensive Care Unit
for further management. At this time, blood cultures that
were taken on [**4-3**], returned with gram positive cocci and
pairs in chains. She was then started on Vancomycin for
coverage. This culture eventually turned out to be
Vancomycin-resistant Enterococcus. Her Vancomycin was then
switched over to Linezolid for coverage. These cultures were
sensitive to Linezolid. On [**4-7**], she was finally
extubated in the Intensive Care Unit. During the following
days, she appeared to go through a psychotic episode and
delirium. A neurologic consultation was obtained. There was
a small lacunar infarct that was visualized on head
computerized tomography scan. The patient had some slight
left-sided weakness, but it was felt that this left-sided
weakness was her baseline. It was felt that her mental
status was mostly secondary to metabolic encephalopathy.
Narcotics were held for agitation, and the patient was given
Haldol instead. The patient was transferred to the floor on
[**2151-4-13**]. A follow up computerized tomography scan was
performed, which found an abdominal abscess that was anterior to
the rectum. She was sent to Interventional Radiology for
drainage of the rectal abscess in a prone position. During
this procedure she had desaturations with a slow recovery.
The patient was on BiPAP with oxygen saturations of 86 to
88%. Because she started to have increasing oxygen
requirements it was best that she be transferred to the
Intensive Care Unit for intubation and further management.
She was given 2 units of packed red blood cells for her
hematocrit of 23.6 which she responded to with a post
transfusion hematocrit of 33. There were no further events
in the Intensive Care Unit and she was finally extubated on
[**2151-4-18**]. During this time, her Levofloxacin and Flagyl
were discontinued. Her pelvic abscess also revealed
Vancomycin-resistant Enterococcus, and her Linezolid and
Fluconazole were continued.
On [**2151-4-19**], the patient was felt to be ready for
transfer to the floor again. Neurologically the patient
began to improve in terms of her mental status. Her tube
feeds were advanced appropriately. A bedside swallowing
evaluation was performed, and the patient did not demonstrate
any aspiration potential. She was then started on clears and
her tube feeds were continued to be advanced to full
strength. During the rest of her hospital course, the
patient's Foley catheter, central line, [**Location (un) 1661**]-[**Location (un) 1662**] drain,
and pigtail catheter were eventually removed. The Neurology
Service felt positive about her neurologic prognosis. She
did demonstrate a dramatic improvement in her mental status
before discharge. Physical therapy also thought that she
would do well at acute rehabilitation placement. Before
discharge to the rehabilitation, the patient was tolerating
tube feeds at full strength at 60 cc/hr. She was also
tolerating some full clears and some soft solids. She
appeared almost to be at her baseline neurologically. Her
case manager ultimately found a spot for her at [**Location (un) 4528**],
[**Location (un) 38**] for which she was screen for appropriately. She is
planned for discharge on [**2151-4-23**] to this facility.
DISCHARGE STATUS: Acute rehabilitation.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Gastric adenocarcinoma.
2. Respiratory failure.
3. Status post jejunostomy redo.
4. Status post small bowel perforation/repair.
5. Hypertension.
6. Sepsis.
MEDICATIONS ON DISCHARGE:
1. Albuterol inhalers.
2. Artificial tears.
3. Aspirin 325 mg q. day.
4. Hydralazine 20 mg p.o. t.i.d.
5. Insulin sliding scale.
6. .................... 0.125 mg q. 4 hours prn for bladder
spasms.
7. Linezolid 300 mg p.o. b.i.d.
8. Lopressor 100 mg p.o. b.i.d.
9. Coumadin, daily dosing to be determined by INR.
Her INR on [**2151-4-23**] was 2.6 which was therapeutic. Her
INR should be between 2 and 3.
FOLLOW UP INSTRUCTIONS: The patient is to follow up with Dr.
[**Last Name (STitle) **] within two weeks. The patient is also to follow up
with Dr. [**Last Name (STitle) 27538**] who is the radiation oncologist, phone
[**Telephone/Fax (1) 32192**]. The patient is to follow up within two weeks.
DISCHARGE DISPOSITION: Discharge facility will be [**Location (un) 32193**], [**Location (un) 38**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2151-4-23**] 09:37
T: [**2151-4-23**] 09:43
JOB#: [**Job Number 32194**]
ICD9 Codes: 0389, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4676
} | Medical Text: Admission Date: [**2177-2-13**] Discharge Date: [**2177-3-2**]
Date of Birth: [**2177-2-13**] Sex: F
Service: NEONATOLOGY
This is an interim dictation summary covering the time period
from [**2177-2-13**] to [**2177-2-28**].
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname 3311**], number
one, is a 1,120 gram girl born at 28 3/7 weeks gestational
age to a 30-year-old G2, P0 to 2 mother with prenatal screens
maternal blood type O negative, DAT negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune, CF
negative, TF negative.
PREGNANCY HISTORY: LMP [**2176-7-16**] for [**Last Name (un) **] [**2177-4-23**],
revised to [**2177-5-5**] based on a 9.5 week ultrasound.
Pregnancy was a spontaneous monochorionic diamnionic twin
gestation with concordant fetal growth.
There was spontaneous onset of preterm labor progressing to
cesarean section for breech presentation in both twins. There
were no sepsis risk factors. The baby was vigorous to
delivery and facial CPAP was provided for intercostal
retractions. Apgar scores were nine at one minute and nine at
five minutes.
The baby was transferred without difficulty to the Neonatal
Intensive Care Unit.
PHYSICAL EXAMINATION: The initial physical examination was
notable for a birth weight of 1,120 grams (50th percentile),
head circumference 27.5 cm (50th to 75th percentile), length
36 cm (25th to 50th percentile). The baby was a
nondysmorphic infant with anterior fontanelle soft and flat.
Palate intact. Moderate nasal flaring, eyelids not fused,
red reflex deferred. There were moderate retractions prior to
intubation with spontaneous breaths, good excursion with
intermittent mandatory ventilation after surfactant
administration, fair breath sounds bilaterally, regular rate
and rhythm with normal femoral pulses and no murmur. The
abdominal examination was benign with no masses and three
vessel umbilical cord, anus patent, normal female genitalia
for gestational age, appropriate neurologic examination.
Spine was normal, hips stable.
HOSPITAL COURSE: 1. RESPIRATORY: The patient was intubated
and two doses of surfactant were administered. The patient
was extubated to CPAP by four days of age, and remained on
CPAP until ten days of age, at which time she was weaned to
room air. At this time, she remained on room air saturating
from 90-100%. Caffeine was initiated on day of life number
four, but she continues to have from one to seven apneic and
bradycardic episodes daily.
2. CARDIOVASCULAR: The patient has remained hemodynamically
stable with no murmur. There are no active cardiovascular
issues.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient
initially received peripheral parenteral nutrition through a
noncentral PICC line. She has been advanced without
difficulty to full enteral feeds and is currently receiving
150 cc per kilogram per day of breast milk supplemented to 26
calories per ounce plus ProMod, all received PG. At the time
of this dictation, the weight was 1,100 grams, still below
birth weight.
4. GASTROINTESTINAL: Maternal blood type O negative, direct
antibody test negative. The baby's blood type is O positive,
DAT negative. Phototherapy was initiated on day of life
number one for a bilirubin of 6 and discontinued on [**2177-2-23**] for a bilirubin of 4.5. The rebound bilirubin is
4.8.
5. HEMATOLOGY/INFECTIOUS DISEASE: Sepsis evaluation was
done for respiratory distress and prematurity. Initial CBC
showed a white blood cell count of 6 with 26% polys and 0%
bands, hematocrit 48%, platelets 268,000. Ampicillin and
gentamicin were given until the blood cultures were negative
for 48 hours. Most recent hematocrit was on [**2177-2-20**] and was decreased to 38. No active hematologic or
infectious disease issues.
6. NEUROLOGIC: Routine head ultrasound was performed on the
seventh day of life and was negative.
7. SENSORY: Hearing screen and ophthalmologic examination
have not yet been performed.
ROUTINE HEALTH CARE MAINTENANCE: Newborn screen was
initially sent on [**2177-2-16**] with normal results. A
repeat newborn screen was sent on [**2177-2-27**]. No
immunizations have been given. The parents wish to have the
twins transferred to [**Hospital3 **] when possible.
CONDITION AT THE TIME OF DICTATION: Stable.
PRIMARY PEDIATRICIAN: Not yet chosen.
MEDICATIONS:
1. Caffeine.
2. Vitamin E.
3. Fer-In-[**Male First Name (un) **].
DISCHARGE DIAGNOSIS:
1. Prematurity at 28 3/7 weeks gestational age.
2. Status post hyperbilirubinemia.
3. Status post sepsis evaluation.
4. Status post surfactant deficiency.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Name8 (MD) 50790**]
MEDQUIST36
D: [**2177-3-2**] 08:38
T: [**2177-3-2**] 21:08
JOB#: [**Job Number 53233**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4677
} | Medical Text: Admission Date: [**2121-5-22**] Discharge Date: [**2121-5-26**]
Date of Birth: [**2063-7-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 57 year old male found down unknown etiology but
appears to have been assaulted who was trasnferred from outside
hospital intubated with SDH. Per report patient was awake on
arrival at OSH and decompensated and required
intubation.
On approach patient is intubate and sedated. He was moving all
extremities with good strength per report. He required sedation
to stay calm.
Past Medical History:
Hep C, EtOH abuse
Social History:
EtOH abuse
Family History:
Non-contributory
Physical Exam:
O: T:98 BP: 140 / 96 HR: 88 R 12 O2Sats 100%
40%
FIO2
Gen: traumatic, multiple facial swelling, abrasions and
rhinorrhea of blood, intubated and sedated/chemically paralyzed
GCS 8T E:2M5V1T
right pupil 1.0 and sluggishly reactive
left canal with cerumen, no otorrhea bilaterally
no battle sign
MAEs bilaterally with purposeful movement off sedation. Very
strong, difficult to hold down
Toes downgoing bilaterally
No clonus
PHYSICAL EXAM UPON DISCHARGE:
Pertinent Results:
[**2121-5-22**] CXR: Endotracheal tube within the mid trachea. No
obvious traumatic injury. Mild cardiomegaly.
[**2121-5-22**] CT Head without Contrast: 11 mm right parieto-occipital
subdural hematoma with minimal interval decrease in subfalcine
herniation, now with 8-mm leftward shift. No frank evidence of
transtentorial herniation. Please see CT of the facial bones
report for details regarding multiple facial fractures.
[**2121-5-22**] CT Torso:
1. No evidence of acute traumatic injury in the chest, abdomen,
or pelvis
2. Nodular liver contour, porta hepatis lymph nodes and
pericholecystic fluid suggest underlying chronic liver disease
or cirrhosis. Correlation with LFTs and clinical history is
recommended.
3. Subcentimeter hypodensities in the left kidney may represent
small cysts or angiomyolipomas.
4. Probable small splenic hemangioma
[**2121-5-22**] CT Max-Face:
1. Comminuted depressed fracture of the roof of the frontal
sinus with blood in the frontal sinuses.
2. Hyperdense air-fluid levels in the maxillary sinuses
bilaterally, right larger than left, suggesting blood. Probably
nondisplaced fracture of the right maxillary sinus lateral wall.
Difficult to exclude fracture of the bilateral maxillary sinus
medial walls.
[**2121-5-23**] CT Head without Contrast: stable
Brief Hospital Course:
Pt was admitted to the Neurosurgery service, ICU for close
neurological observation. He was started on dilantin for seizure
prophylaxsis, and blood pressure was kept < 140 systolic.
Patient was stabilized and exubated. His c-spine was cleared.
Seen by plastics for facial fractures; they placed 2 sutures on
nose and recommended sinus precautions with augmentin x2 weeks.
Repeat head CT on [**5-23**] revealed no interval change in hemorrhage.
Patient was subsequently transfered to the floor. Throughout
his hospitalization, patient was monitored for signs of EtOH
withdrawal but did not require benzodiazepines.
PT was consulted and patient was deemed appropriate for
discharge home. A plan was put in place with social work for
the patient to discharge safely to his mother's home.
At the time of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Nadolol 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
max 4g/24 hr
2. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 14 Days
First day = [**2121-5-22**]
Last day = [**2121-6-4**]
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet(s) by
mouth every 12 hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Phenytoin Sodium Extended 100 mg PO TID
RX *Dilantin Extended 100 mg 1 Capsule(s) by mouth Three times
daily Disp #*90 Capsule Refills:*1
6. Nadolol 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**11-18**] Tablet(s) by mouth every 4 hours as
needed for pain Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? You have been prescribed Dilantin (Phenytoin), take it as
prescribed and follow up with laboratory blood drawing in one
week. This can be drawn at your PCP??????s office, but please have
the results faxed to [**Telephone/Fax (1) 87**].
?????? Do not drive until your follow up appointment.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2121-5-26**]
ICD9 Codes: 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4678
} | Medical Text: Admission Date: [**2101-12-17**] Discharge Date: [**2101-12-22**]
Date of Birth: [**2045-5-15**] Sex: M
Service: PLASTIC
Allergies:
Novocain
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
left multidigit trauma, s/p table saw injury
Major Surgical or Invasive Procedure:
1. left index digital artery, digital nerve repair radial and
ulnar nerve repair x2
2. radial lateral collateral ligament repair
3. left long finger radial digital artery repair
4. left long finger digital artery, digital nerve radial and
ulnar repair x2
5. left long finger flexor digitorum profundus repair
6. left ring finger radial digital artery repair with
microvascular anastomosis
7. left ring finger radial and ulnar digital nerve repair x2
8. left ring finger flexor digitorum profundus repair
9. A1 pulley release
10. repair of lacerations, 20-cm
11. dissection of dorsal vein for vein graft harvest
History of Present Illness:
56yo male right-hand dominant OSH transfer with traumatic injury
to left hand with table saw at approximately 1230p today.
Patient states hand slipped and was caught by table saw.
Immediately after the incident, patient reports moderate pain
and placed clenched injured hand in right hand and proceeded to
emergency department. Patient notes general numbness of digits
[**1-26**] and inability to flex digit 4. Patient received cefazolin
and tetanus booster at outside hospital.
Past Medical History:
MI ([**2081**]), hyperlipidemia, GERD, nephrotic syndrome,
pneumothorax
Social History:
works as commercial driver
tob - 2pk/day, prev 4pk/day
EtOH - social
illicit - denies
Family History:
non-contributory
Physical Exam:
upon admission:
General - AOx3, NAD
Chest - CTAB
CV - RRR, S1/S2 appreciated
Abd - soft, nontender, nondistended
Extremity - left upper extremity: patient with significant
multiple injuries of the hand as follows.
1st digit: laceration of the volar aspect along the MCP, no
exposed tendon; capillary refill < 1sec; sensation to light
touch
intact over entire digit
2d digit: deep laceration along radial aspect of digit from MCP
and extending along volar aspect exposing flexor tendons;
capillary refill < 1sec, dopplerable signal over both radial and
ulnar digital arteries; patient reports altered sensorium over
the finger
3d digit: deep laceration on volar aspect between the MCP and
PIP
joints with exposed flexor tendons; finger is cool to touch,
capillary refill < 2sec, no dopplerable signal in digital
arteries distal to injury; patient with no sensation over digit
distal to injury
4th digit: deep laceration on volar aspect at level of the PIP
with visualization of volar aspect of PIP joint; finger is cool
to touch, capillary refill < 2sec, no dopplerable signal in
radial digital artery distal to injury site, weakly dopplerable
signal in ulnar digital artery distal to injury site; patient
with no sensation over digit distal to injury
5th digit: laceration on volar aspect at level of DIP with no
exposed flexor tendon; capillary refill < 1sec, dopplerable
signal of both radial and ulnar digital arteries; sensorium to
light touch intact
Pertinent Results:
[**2101-12-17**] 07:15PM GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-11
[**2101-12-17**] 07:15PM estGFR-Using this
[**2101-12-17**] 07:15PM WBC-17.4*# RBC-4.48* HGB-14.7 HCT-42.1 MCV-94
MCH-32.7* MCHC-34.9 RDW-12.9
[**2101-12-17**] 07:15PM NEUTS-82.0* LYMPHS-15.0* MONOS-2.5 EOS-0.1
BASOS-0.3
[**2101-12-17**] 07:15PM PLT COUNT-280
[**2101-12-17**] 07:15PM PT-11.6 PTT-27.0 INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2101-12-17**] and had the following procedures:
1. Left index digital artery, digital nerve repair radial and
ulnar nerve repair x2
2. Radial lateral collateral ligament repair
3. Left long finger radial digital artery repair
4. Left long finger digital artery, digital nerve radial and
ulnar repair x2
5. Left long finger flexor digitorum profundus repair
6. Left ring finger radial digital artery repair with
microvascular anastomosis
7. Left ring finger radial and ulnar digital nerve repair x2
8. Left ring finger flexor digitorum profundus repair
9. A1 pulley release
10. Repair of lacerations, 20-cm
11. Dissection of dorsal vein for vein graft harvest
The patient tolerated the procedures well
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#0. Intake
and output were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cefadroxil upon discharge. The patient's
temperature was closely watched for signs of infection.
Prophylaxis: The patient was initally started on a heparin drip
post-operatively for 48 hours and subsequently received
subcutaneous heparin after discontinuation of the drip. The
patient was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
nexium, lipitor, enalapril
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 500 mg Capsule Sig: [**12-24**] Capsules PO Q6H (every
6 hours) as needed for pain, fever.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*50 Capsule(s)* Refills:*2*
9. Cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
left multi-digit trauma, status post table saw injury
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
* keep your left hand in the doral blocking splint at all times
except when showering
* while showering, you may either take off the splint and let
water indirectly run over the left hand (no soap) or place the
splint and hand in a plastic bag to keep dry
* a visiting nurse has been arranged for daily dressing changes
* continue to refrain from caffeine or nicotine intake
* continue aspirin and antibiotics until follow-up in Hand
Clinic
Return to the ER if:
* If you develop worsening pain, loss of function, or futher
loss/worsening of sensation in your left upper extremity
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Hand Clinic - please call [**Telephone/Fax (1) 3009**] to schedule an
appointment for [**2101-12-27**]
Completed by:[**2101-12-22**]
ICD9 Codes: 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4679
} | Medical Text: Unit No: [**Numeric Identifier 75492**]
Admission Date: [**2109-9-22**]
Discharge Date: [**2109-10-15**]
Date of Birth: [**2109-9-22**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 75493**] is a 40 [**12-9**] week infant born on
[**2109-9-22**]. She was born to a 26-year-old gravida 3,
now para 1 mother by cesarean section and with [**Name (NI) **] scores
of 9 at 1 minute and 9 at 5 minutes. Her birth weight was
3.854 kg (8 pounds, 8 ounces).
PRENATAL SCREENS: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, and group B status negative.
ANTEPARTUM COURSE: The maternal history and pregnancy were
notable for methadone use. The mom is on 150 mg per day of
methadone. The mom reported no use of any illegal drugs upon
learning that she was pregnant. The mom's urine toxicology
screen was positive for methadone, and the baby's urine
toxicology screen (taken after NOS was already initiated) was
positive for methadone and opiates (a pos opiate screen would
be expected after initiation of NOS).
ADMISSION PHYSICAL EXAMINATION: The baby was active and
alert. Her weight was 3.854 kg (8 pounds, 8 ounces - in the
90th percentile), length 19.25 inches (50th percentile), and
head circumference 35.5 cm (90th percentile). Breath sounds
were clear to auscultation bilaterally. Her heart rate was
regular, with no murmur, and femoral pulses were 2+
bilaterally. The red reflex was present bilaterally. The
abdomen was benign, without hepatosplenomegaly.
Neurologically, she was alert and moving all extremities, and
reflexes were symmetric. Her overall tone was increased.
HOSPITAL COURSE:
1. Respiratory. There were no issues. Breath sounds were
clear and equal bilaterally.
2. Cardiovascular. She had a regular rate and rhythm, no
murmur, and 2+ femoral pulses bilaterally. A soft systolic
(1/VI) was appreciated on dol #14; baby underwent cardiac eval
(ekg, cxr, bp, pre/post ductal sat) which was wnl (EKG with
prom LV axis).
3. Fluids, electrolytes, and nutrition. She is tolerating
ad. lib. feedings of Carnation Good Start well. She was
changed to Enfamil 24 kcal for poor wt gain, but has posted good
wt gain thereafter. Changed back to 20 kcal Good Start with
good wt gain. Her
weight on the day of discharge is 9 lb 1 oz (4120 gm)..
4. Infectious disease - No issues.
5. Gastrointestinal. Her bilirubin on [**2109-9-24**] was
12.1.
6. Neurological. [**Doctor First Name 56581**] has had overall increased tone.
She was started on neonatal opium solution on [**9-24**], [**2108**], day of life #2. She is presently receiving
0.36 mL of 0.4 mg/mL solution every 4 hours. BABY SHOULD BE
WEANED AGAIN TODAY: UPON ARRIVAL TO [**Hospital1 **], DOSING SHOULD
CHANGE TO NOS (0.4 MG/ML MORPHINE): 0.27 ML PO Q 4 HR. REASSESS
ON [**10-16**] AM BASED ON NAS [**Doctor Last Name **]. Recent
score today: [**1-7**]. Her mother is currently on
methadone 150 mg per day. [**Doctor First Name 56581**] has been followed by
occupational therapy and has received appropriate
developmentally supportive care.
7. Sensory. Audiology - Passed BAERS b/l.
8. Psychosocial. [**Hospital1 69**]
Social Work has been involved with this mother. The
contact social worker is [**Name (NI) **] [**Name (NI) 47799**]. She can be
reached at [**Telephone/Fax (1) 8717**]. A 51A has been filed with DSS
and was screened out by [**Hospital1 **] area DSS. The case was
reopened by DSS when mother was found asleep on at least 3
separate occasions with baby in her arms, between legs, and
wedged alongside her in a chair during mother's hospitalization,
but case was again screened out by DSS after further
investigation. Baby will eventually be discharged to home in
mother's custody.
CONDITION ON TRANSFER: Good.
DISPOSITION: To [**Hospital3 **].
PRIMARY CARE PEDIATRICIAN: [**Hospital1 2025**] [**Location (un) 3146**].
CARE RECOMMENDATIONS:
1. Feeding at discharge: Enfamil 24 kcal ad lib.
2. Medications: Neonatal opium solution (0.4 mg/mL morphine):
BABY SHOULD BE WEANED UPON ARRIVAL TO [**Hospital1 **] TO 0.27 mL PO
every 4 hours. BABY [**Month (only) **] NEED ONE ADDITIONAL WEAN BEFORE
D/CING NOS COMPLETELY -- WE D/C WHEN WE REACH 25% OF THE
ORIGINAL DOSE, WHICH WAS 0.9 ML Q 4HR).
3. State newborn screening sent on [**2109-9-24**] -
results pending.
4. Immunizations received: Hepatitis B vaccine [**2109-9-26**].
5. Car seat test: Not applicable.
6. Immunizations recommended:
a.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 all household contacts and out-of-home
caregivers.
FOLLOW-UP RECOMMENDATIONS:
1. Pediatric care.
2. Progressive weaning from NOS.
3. Early intervention.
DISCHARGE DIAGNOSIS:
1. Term, average-for-gestational-age female.
2. Neonatal abstinence syndrome (intra uterine methadone
exposure).
3. s/p cardiac eval for soft systolic murmur: prom LV axis, but
otherwise wnl .
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 71194**]
Dictated By:[**Doctor Last Name 55781**]
MEDQUIST36
D: [**2109-9-24**] 17:04:59
T: [**2109-9-25**] 10:06:05
Job#: [**Job Number 75494**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4680
} | Medical Text: Admission Date: [**2117-9-9**] Discharge Date: [**2117-10-28**]
Date of Birth: [**2075-7-20**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Night sweats, fevers, weight loss, abnormal CBC
Major Surgical or Invasive Procedure:
Bone marrow biopsies (iliac crest and sternal)
Lumbar puncture and intrathecal chemotherapy
CVC placement
History of Present Illness:
Mr. [**Known lastname 58834**] is a 42-year-old gentleman with a history of anxiety
who was in his usual state of health until roughly three weeks
ago. At that time he started to feel increasingly fatigued. He
noted that he was short of breath, even with minimal exertion,
which was unusual for him. He also started to develop chills
and drenching night sweats. About two weeks ago he started to
notice a pain in his left side. Last week he saw his PCP who
thought he had a URI and a muscle strain and he was started on
Avelox and Percocet. Since then he has had intermittent nausea
and vomiting. This was thought be secondary to the Avelox so
his antibiotics were switched two days ago (he cannot recall to
what). He has continued to have nausea with minimal vomiting.
His appetite and po intake have been poor. For the last week he
has had fevers nightly to 100.2 and the drenching night sweats
have continued. He returned to his PCP on day of admission who
sent a CBC which was significant for anemia and
thrombocytopenia, as well as a WBC of 16 with an abnormal
differential. He was sent in the ED for further evaluation. Per
patient's report, he has had "normal blood work" in the past and
has never been anemic.
.
Prior to the last few weeks, he was feeling well. He has not had
any other illnesses recently. He denies any headaches or visual
changes. He has shortness of breath when climbing up the stairs
or performing basic ADLs. He notes intermittent chest tightness
that "comes and goes" which is more chronic for him. He had an
episode of diarrhea yesterday. No blood in his stool. No
urinary symptoms. No gingival bleeding or epistaxis. He has not
noted any rash. No lower extremity edema.
Past Medical History:
Anxiety and seasonal allergies
Social History:
Patient is divorced. He has two kids aged 16 and 14. He is from
[**State 350**] and lives in [**Location 1475**]. He is self-employed and
owns a concession in [**Location (un) **] [**Location (un) 84578**]. He denies exposure to
chemical, toxins, heavy metals. He has never smoked and drinks
alcohol socially. He started using intra-nasal cocaine during
the past year, last used in mid-[**Month (only) **].
Family History:
Father - CAD, CABG at 43, died of SCLC earlier this year
Mother - renal failure, s/p transplant
1 brother, 2 sisters - all healthy
2 children are healthy
No other FH of malignancy, leukemia, lymphoma
Physical Exam:
: 100.8 HR: 90 BP: 119/71 RR: 18 SAT: 93% ra, 95% 2L nc
Gen: NAD, diaphoretic
HEENT: PERRLA, EOMI, sclerae anicteric. OP - petechiae over
posterior palate
Neck: supple
Lymph: no supraclavicular, submandibular, cervical or axillary
LAD
Resp: CTAB
CV: RRR, no MRG appreciated
Abd: + BS, soft, obese, TTP in LUQ extending around to L flank,
+ splenomegaly
[**Doctor Last Name **]: non-tender to palp over spine, paraspinal muscles
Ext: no edema or calf tenderness
Skin: petechiae over lower extremities
Neuro: aao x 3, answering questions appropriately
Pertinent Results:
[**2117-9-10**] 12:00AM GLUCOSE-100 UREA N-16 CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2117-9-10**] 12:00AM ALT(SGPT)-20 AST(SGOT)-49* LD(LDH)-1755* ALK
PHOS-81 TOT BILI-0.8 DIR BILI-0.2 INDIR BIL-0.6
[**2117-9-10**] 12:00AM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-4.1
MAGNESIUM-2.1 URIC ACID-6.4
[**2117-9-10**] 12:00AM HAPTOGLOB-275*
[**2117-9-10**] 12:00AM WBC-10.0 RBC-2.40* HGB-7.5* HCT-21.0* MCV-88
MCH-31.1 MCHC-35.5* RDW-17.6*
[**2117-9-10**] 12:00AM NEUTS-8* BANDS-3 LYMPHS-36 MONOS-0 EOS-0
BASOS-0 ATYPS-4* METAS-1* MYELOS-0 OTHER-48*
[**2117-9-10**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2117-9-10**] 12:00AM PLT SMR-VERY LOW PLT COUNT-23*
[**2117-9-10**] 12:00AM PT-15.8* PTT-27.4 INR(PT)-1.4*
[**2117-9-10**] 12:00AM FDP-10-40*
[**2117-9-10**] 12:00AM FIBRINOGE-594*
ECHO [**9-9**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60-70%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
CT TORSO [**9-10**]
IMPRESSION:
1. Enlarged and fatty liver.
2. Massive spleen. Nonspecific hyperdensity in the posterior
aspect of the
spleen.
3. Prominent lymph nodes in the porta hepatis, and portacaval
lymph node,
with a large number of small retroperitoneal lymph nodes.
4. Left kidney is low positioned, but likely from an enlarged
spleen.
5. Small left fat-containing hernia.
6. Transverse colon compressed below the tip of the spleen, of
uncertain
clinical significance, correlate with clinical symptoms (if
any).
MRI HEAD [**10-3**]:
IMPRESSION: Focal acute infarction which appears to be
cortically-based, in a
non-arterial vascular distribution involving the left frontal
and parietal
lobes. Susceptibility artifact in the overlying veins and
superior sagittal sinus is concerning for venous thrombosis. The
findings likely represent acute venous infarction. A tiny focus
of T1 hyperintensity in the left temporal lobe may represent a
small focus of hemorrhage, which progresses rapidly to become
much larger on the subsequent head CTs.
A wet [**Location (un) 1131**] was given by the resident to Brit Guims at 5:10
p.m. on [**2117-10-3**] stating "Cortically based infarct DWI/ADC
abnormality in the left parietal area involving pre- and mainly
post-central gyrus area consistent with acute infarct. GRE
blooming in the left M4 cortical branches may indicate clot and
seen to vertex."
An additional [**Location (un) 1131**] describing the venous nature of the acute
infarct and acute thrombosis of cortical veins and the superior
sagittal sinus was given to Dr. [**First Name8 (NamePattern2) 3461**] [**Name (STitle) 12332**] (Neurology
service) at 11:00 a.m. on [**2117-10-4**], and the findings were fully
discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], by Dr. [**Last Name (STitle) **], shortly
thereafter.
CT HEAD [**2117-10-4**]:
Large hemorrhagic transformation of left MCA territory infarct
with severe increased edema and rightward shift of midline
structures to 7 mm, up to 4 mm. New hyperdense focus medial to
existing hemorrhage measuring 4 x 5 mm. Possible left uncal
herniation also.
CT HEAD [**2117-10-6**]: Stable extent of large hemorrhage in the left
frontoparietal lobes with stable rightward shift of midline
structures. No new areas of hemorrhage seen.
CT head [**2117-10-16**]:
1. Evolution of left frontoparietal hemorrhage with increased
rightward shift from 6 to 12 mm.
2. No new hemorrhage.
3. Basal cisterns are preserved.
4. Enlargement of temporal [**Doctor Last Name 534**] of right lateral ventricle is
suggestive of subfalcine herniation.
CT abdomen and pelvis with contrast [**2117-10-27**]:
1. Splenomegaly with a moderate-to-large wedge-shaped area of
hypoperfusion
and a smaller ovoid area posteriorly of hypoperfusion, both of
which most
likely represent splenic infarct.
2. Minimally prominent bowel wall involving the descending colon
with
adjacent mesenteric stranding. This appearance is nonspecific,
given the
descending colon is entirely decompressed. However, this might
be consistent
with the patient's clinical history of C. diff colitis.
Brief Hospital Course:
The patient is a 42-year-old gentleman with a history of anxiety
who presented from [**Hospital 1474**] hospital with fevers, night sweats,
weight loss, and a peripheral smear showing 30% blasts. He was
admitted to BMT service for work-up and treatment of ALL.
.
ACUTE LEUKEMIA: Patient with 30% blasts on peripheral smear and
differential suggestive of acute leukemia. Upon admission, Mr.
[**Known lastname 58834**] was started on IVF and allopurinol. He was treated
supportively with red cell and platelet transfusions. Serial
CBCs, tumor lysis labs, and coagulation profiles were sent to
rule out tumor lysis and DIC. He underwent and echocardiogram,
EKG, and screening CT scan; triple lumen was placed in right IJ.
Bone marrow biopsy on day 1 of admission showed acute
lymphoblastic leukemia. Patient was offered enrollment in
Clinical Trail DF#06-254 for treatment of adult ALL, and he
accepted. A sternal bone marrow aspirate was performed. On day
#2 of trial, patient had LP with intrathecal Ara-C, and he was
started on methyl-prednisolone 27mg Q8. He underwent treatment
with vincristine, doxorubacin, peg L-asparaginase per [**Company 2860**]
protocol for ALL. Upon discharge, he is day 48 of [**Company 2860**]
protocol.
Repeat bone marrow biopsy was not performed at this time given
the patient's overall condition, and the fact that given his
elevated liver enzymes, he would not be a candidate to undergo
further therapy at this time. However, a repeat bone marrow
biopsy may be performed in the future should the patient's
condition improve. He will follow-up with his oncologist Dr.
[**Last Name (STitle) **] on [**2117-11-8**] for further management.
.
CENTRAL VENOUS THROMBOSIS /HEMORRHAGIC CONVERSION
While on BMT service on [**2117-10-3**] in the morning, the patient was
noted to be less responsive with global aphasia and right sided
hemiparesis. MRI at the time showed evidence for ischemic stroke
in the left parietal lobe. Upon transfer to the [**Hospital Unit Name 153**] around 5pm,
he was globally aphasic, making purposeless movements on the
left side but not moving his right, with upgoing toes on Right
(+ Babinksi). CT on arrival to ICU revealed massive hemorrhagic
transformation of left MCA territory infarct with severe
increased edema and rightward shift of midline structures. En
route to the ICU from CT, Mr. [**Known lastname 58834**] became extremely flushed,
diaphoretic and nauseous, likely secondary to increased
intracranial pressure from massive bleed and edema, and he began
vomiting. Due to inability to protect his airway, he was
intubated with anesthesia at the bedside. Due to intense
systolic hypertension at the time of intubation (SBP 223) he
received 20mg IV hydralazine as well as sedation with fentanyl,
propofol and midazolam which normalized his blood pressures. He
received blood products, FFP, cryo, fibrinogen and factor VII.
Neurology and Neurosurgery were consulted and Neurosurgery
considered placement of extraventricular drain to help relieve
intracranial pressure and prevent impending herniation, but upon
discussion with Mr. [**Known lastname 84579**] family including his brother who is
his health care proxy, the procedure was declined.
The following day, Neurology evaluation of imaging revealed
superior sagginal sinus thrombosis and suggested 4 vessel
angigraphy and possible angio-jet procedure to evacuate the
thrombus. After discussing the long term prognosis with the
family, the decision was made for the patient not to undergo the
procedure. However, upon further discussion with Neurosurgery
and the Bone Marrow Transplant team, a decision was made to
start less invasive options -- hyperventilation and Mannitol to
see how the patient responds.
Over the next several days, the patient's condition
stabilized. Findings on CT of the head remained stable. The
patient was successfully extubated on [**2117-10-8**] and was
transferred back to BMT service on [**2117-10-10**] for further
management. He was not anticoagulated due to his persistent
thrombocytopenia and intracranial hemorrhage. Repeat CT was
performed after the patient's return to the floor and revealed
worsening midline shift. However, the patient's neurological
exam remained stable. Neurological exam was performed every 4
hours. Neurology stroke service was consulted and did not feel
that radiolographic findings were more concerning. The patient
continued to be able to follow simple verbal commands. However,
he remained hemoplegic on the right side, other than occasional
wiggle of the right toes. He also remained aphasic. However,
he began to show more awareness of his environment in the last
two days prior to his discharge. He was nodding appopriately to
express his understanding of verbal communication. Per
discussion with neurology, anticoagulation is not indicated in
this case and was not re-started.
.
HYPERBILIRUBINEMIA AND TRANSAMINITIS: Following chemotherapy,
the patient was noted to have progressively increasing liver
function tests and bilirubin levels. The patient was evaluated
by liver consult. While etiology of hyperbilirubinemia and
transaminitis were not clear, it was believed that vincristine
was the most likely cause. Liver biopsy was not performed given
the patient's condition. Total bilirubin levels peaked at 12.0,
and gradually declined from there. At the time of discharge,
total bilirubin levels are 2.5 and continue to decline.
.
FEVERS: In ED, patient was started on cefepime and vancomycin
for neutropenic fever. Blood cultures and urine cultures were
negative. There was no indication of infection on CT. While in
the ICU, the patient also developed low grade fevers and was
started on Micafungin for antifungal coverage, which was
subsequently switched to Anidulafungin. Broad spectrum
antibiotics were stopped upon return to the BMT floor and
resolution of patient's neutropenia as well as fevers. The
patient remained afebrile. He developed low grade fevers two
days prior to discharge associated with loose stools. Repeat C.
diff toxin test came back positive. Urinalysis was also
significant for 9 WBCs although no bacteria. CXR was performed
and showed no evidence of acute pulmonary process. The patient
was started on Ciprofloxacin for empiric treatment of UTI and
oral Flagyl plus Vancomycin for treatment of C. diff colitis.
Urine culture came back negative and Ciprofloxacin was
discontinued prior to discharge. The patient should continue
oral Vancomycin for a 14 day total course.
.
ANXIETY: Patient was continued on Zoloft 200mg QD. He was
given ativan prn for anxiety.
.
THROAT LESIONS: Mr. [**Known lastname 58834**] complained of throat pain/soreness
upon admission. Inspection of the back of his throat revealed
small nodules and erythema, suggestive of HSV reactivation. Mr.
[**Known lastname 58834**] was started on acyclovir for treatment of HSV. Acyclovir
is being continued upon discharge.
.
C. DIFF INFECTION: While in the ICU, the patient was noted to
have loose stools and tested positive for C. diff infection. He
underwent a 14 day course treatment with PO Flagyl, with
resolution of his diarrhea. He again developed low grade
fevers, abdominal pain and loose stools two days prior to
discharge. Repeat stool test for C. diff toxins came back
positive. The patient was re-started on PO Vancomycin and PO
Flagyl for empiric treatment of of C. diff. CT of abdomen was
performed and revelealed mild wall thickening in the descending
colon, but no clear evidence of colitis. He is scheduled to
complete a 14 day course of PO Vancomycin and a 5 day course of
PO Flagyl, after which he should be re-evaluated for persistent
C. diff. Oxycodone PRN for given for pain contol.
.
SPLENIC INFARCT: The patient has a ssignificant splenomegaly
secondary to his ALL. He was noted to have two areas of splenic
infarction on CT of abdomen and pelvis performed on [**2117-10-27**].
It is believed that infarction was caused by insufficient blood
supply to his enlarged spleen. No intervention was performed.
The patient was given Oxycodone via G-tube as needed for pain
control.
.
RIGHT IJ VEIN CLOT: While in the ICU, the patient was noted to
have right upper extremity swelling. A Right upper extremity
ultrasound found a clot in the right internal jugular vein,
which provoked by right subclavian central venous line. The
patient was not anticoagulated given patient's chronic anemia
and thrombocytopenia. CVL was removed. PICC line was placed
for hydration, TPN and administration of medications.
.
NUTRITION: The patient failed speech and swallow evaluation
following his stroke. He was made NPO and was transiently
maintained on TPN. G-tube was successfully placed by
Interventional Radiology service. The patient was started on
eneteral nutrition by tube feeds, which he has tolerated well.
Medications on Admission:
Zoloft 200mg QD
Discharge Medications:
1. Prochlorperazine Maleate 10 mg Tablet [**Date Range **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
2. Levetiracetam 100 mg/mL Solution [**Date Range **]: Five (5) ml PO BID (2
times a day).
3. Ursodiol 300 mg Capsule [**Date Range **]: Three (3) Capsule PO BID (2
times a day).
4. Metronidazole 500 mg Tablet [**Date Range **]: One (1) Tablet PO Q8H (every
8 hours) for 4 days: Last day = [**2117-11-1**].
5. Oxycodone 5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 14 days: Day 1 = [**2117-10-27**]
Last day = [**2117-11-9**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Acute Lymphocytic Leukemia, Central Venous Thrombosis
with Hemorrhagic Conversion, Hyperbilirubinemia and
Transaminitis, C. diff colitis.
Discharge Condition:
Afebrile, Vitals stable, Aphasia and Right Hemiplegia
Able to follow simple verbal commands
Unable to ambulate
Discharge Instructions:
You were admitted to the hospital for treatment of your Acute
Lymphocytic Leukemia. You underwent treatment with chemotherapy
per [**Company 2860**] protocol. Subsequently, you developed elevated liver
function tests, which is a sign of liver inflammation. You also
suffered a stroke (central venous thrombosis with hemorrhagic
conversion) that left you paralyzed on right side of the body
and unable to speak. You were intubated for protection of your
airway and monitored closely in the intensive care unit, where
you were treated with mannitol and hyperventilation to reduce
your brain swelling. You neurological function slowly improved,
but you continue to have many neurological deficits as a
consequence of your stroke. You are now being discharged for
neurological rehabilitation.
We started you on the following medications:
1. Prochlorperazine Maleate 10 mg Tablet PO Q6 hours as needed
for nausea.
2. Levetiracetam 100 mg/mL Solution [**Company **]: Five (5) ml PO BID
(2 times a day).
3. Ursodiol 300 mg Capsule [**Company **]: Three (3) Capsule PO BID (2
times a day).
4. Metronidazole 500 mg Tablet [**Company **]: One (1) Tablet PO Q8H
(every 8 hours) for 4 days: Last day = [**2117-11-1**].
5. Oxycodone 5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H
(every 6 hours) for 14 days: Day 1 = [**2117-10-27**] Last day =
[**2117-11-9**].
You should continue to take nothing by mouth. You will receive
nutrition via tube feeds.
You have a follow-up appointment with Dr. [**Last Name (STitle) **] (see below).
You should return to the emergency room should you develop any
of the following: fevers over 101F, chills, unresponsiveness,
severe pain not releaved by medications, new neurological
deficits.
Followup Instructions:
You have an appointment with your oncologist Dr. [**First Name (STitle) **]
[**Name (STitle) **] on [**2117-11-8**] at 1:00 pm in [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 436**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2117-12-24**]
ICD9 Codes: 486, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4681
} | Medical Text: Admission Date: [**2113-9-11**] Discharge Date: [**2113-9-15**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
weakness, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81yo woman with PMH significant for myasthenia [**Last Name (un) 2902**], COPD, PE,
and extensive smoking history, p/w weakness and dyspnea. She had
been in her USOH until approximately [**Month (only) 547**], and since then has
been getting progressively weaker. She was diagnosed with
bilateral PEs in [**Month (only) **] and also noted to have paroxysmal atrial
fibrillation, for which she was started on coumadin. She feels
she has been relatively stable in terms of her myasthenia. She
says that [**Last Name **] problem is more weakness than difficulty
breathing. She has no diplopia, dysphagia, fevers, chills. She
reports PND and lower extremity edema.
Past Medical History:
1. Myasthenia [**Last Name (un) **] diagnosed in [**11-1**], status post plasma
exchange, CellCept, Mestinon and prednisone. She last had plasma
exchange in 04/[**2113**]. + AChR Ab, EMG consistent with MG.
2. Thymus resection [**2111-12-1**] with pathology consistent with
follicular B-cell hyperplasia.
3. Severe sensorimotor polyneuropathy. Work-up with unremarkable
LP [**2111**] (0W, 0R, 24 prot, 82 gluc, lyme neg, VDRL NR, negative
oligoclonal bands, cultures negative), normal SPEP/UPEP, and
normal folate. B12 borderline low.
4. Essential tremor
5. Glaucoma
6. Mild restrictive lung defect, last PFTs with FVC 0.92 (39%),
FEV1 0.63 (40%), FEV1/FVC 68 (102%). DlCo 49% in 04/[**2113**].
7. Osteoarthritis of hands bilaterally
8. Urinary incontinence9. Preserved systolic function with
EF>75% on echo 04/[**2111**].
Social History:
Widowed x 15 years, no kids. She is currently living with her
cousin in [**Name (NI) 18825**], [**State 350**]. She is retired from working as
a supervisor for an insurance company in [**Location (un) 86**]. She does not
drink alcohol or use illicit drugs. She smoked from one to one
and a half packs per day for approximately 30 years but quit 30
years ago.
Family History:
mother died 52yo of DM complications
father died 59yo of CHF
brother with DM
brother with eye problems
No history of myasthenia in family.
Physical Exam:
Admission exam:
VS: T98, BP 128/61 (120-128/45-61), HR 73(73-96), RR 24, SaO2
100%/3L, NIF<-20, FVC 400s (but ?effort)
Genl: comfortable, lying in bed
HEENT: NCAT, MMM, OP clear, conjunctival pallor
CV: irregularly irregular, no m/r/g appreciated
Chest: decreased air flow in BUL, no crackles/wheezes
Abd: soft, NTND, BS+
Rectal: guaiac negative per MSIII
Ext: warm, 3+ pitting edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Speech is fluent
with normal comprehension and repetition. No dysarthria. No
right-left confusion. No evidence of neglect. Registration [**3-31**],
recall [**1-31**] with cue.
Cranial Nerves:
Pupils equally round and reactive. Extraocular movements intact
bilaterally, no nystagmus. No diplopia on sustained upgaze. +R
ptosis. Sensation intact V1-V3. Facial movement symmetric.
Hearing grossly intact. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact.
Motor: Normal bulk bilaterally. Tone normal. No observed
myoclonus, mild intention tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] FE FF IP
R 4- 4 4+ 4 5 4- bilateral foot drop
L 4- 4- 4+ 4- 5 4+
Sensation: intact to light touch, pin prick, temperature (cold),
vibration, and proprioception in all extremities.
Reflexes: absent
Gait: deferred.
Discharge exam:
General examination, MS, CN, sensation essentially unchanged.
Strength has improved, with 4/5 neck flexors and [**6-2**] neck
extensors. Otherwise, left side slightly improved with 4/5 R
delts, and [**6-2**] biceps.
NIF and FVC have been determined to be inaccurate secondary to
significant air leak, but she is able to count to 28 in one
breath, which is her baseline.
Pertinent Results:
Admission labs:
WBC-6.8 RBC-3.67* Hgb-9.3* Hct-28.8* MCV-78* MCH-25.3* MCHC-32.3
RDW-15.7* Plt Ct-473*
Neuts-91.1* Lymphs-6.4* Monos-2.3 Eos-0 Baso-0
PT-23.2* PTT-24.3 INR(PT)-2.3*
Glucose-122* UreaN-23* Creat-0.8 Na-136 K-4.5 Cl-96 HCO3-33*
Calcium-8.8 Phos-3.5 Mg-2.4
ALT-13 AST-16 LD(LDH)-181 CK(CPK)-16* AlkPhos-35* TotBili-0.3
Other labs:
calTIBC-343 Ferritn-18 TRF-264
VitB12-GREATER TH Folate-17.3
TSH-3.0
TSH-2.0
SPEP pending
ALT-13 AST-16 LD(LDH)-181 AlkPhos-35* TotBili-0.3
[**2113-9-12**] 02:41AM BLOOD CK(CPK)-16* CK-MB-NotDone cTropnT-<0.01
[**2113-9-12**] 03:31PM BLOOD CK(CPK)-19* CK-MB-NotDone cTropnT-<0.01
U/A negative
Bcx pending
Discharge CBC:
[**2113-9-15**] 07:10AM BLOOD WBC-6.7 RBC-4.40 Hgb-11.2* Hct-34.7*
MCV-79* MCH-25.5* MCHC-32.3 RDW-16.0* Plt Ct-381
CXR: No focal consolidations or congestive heart failure.
Brief Hospital Course:
81yo woman with past medical history significant for myasthenia
[**Last Name (un) 2902**], chronic obstructive pulmonary disease, pulmonary
embolus, and obstructive sleep apnea presenting with subacute
onset of dyspnea. Her exam was remarkable for decreased air flow
but FVC at baseline. Labs showed a Hct of 26, and CXR was
unremarkable.
Hospital course is detailed below by problem:
1. dyspnea - This was most likely multifactorial and secondary
to anemia, COPD, apnea, PEs, and myasthenia. She was initially
admitted to the ICU for overnight observation; she remained
stable there and was transferred to the step-down unit. Once
there, she was transfused two units PRBCs and immediately felt
better. Her myasethenia medications were continued and not
changed per neuromuscular recommendations; in fact, her
myasthenia remained at baseline and was likely not the reason
for her dyspnea. She was monitored with NIFs and FVCs initially,
but it was later determined that these were likely inaccurate
secondary to significant air leak around the tube. Clinically,
she remained stable and was able to count to 28 in one breath
during the entire admission, with increased ability to walk as
well. She was started on CPAP overnight, which she tolerated for
approximately 6 hours. She did not like it only because it was
not humidified (unable to obtain a humidified CPAP within the
hospital) and therefore made her throat sore and dry. Her COPD
regimen was changed to standing atrovent q6h and prn albuterol.
Her case was discussed with the pulmonary team, who recommended
outpatient follow up, which was scheduled. She was no longer
feeling dyspneic and fatigued (at baseline).
2. anemia - This was consistent with iron deficiency anemia,
with a Fe of 14, a low ferritin, and a high-normal TIBC. Per
hematology, cellcept is more likely to cause leukopenia than the
rare red cell aplasia. She has been on the cellcept long before
she became anemic. Guaiacs were negative, retic count, B12, and
folate nl. Her iron supplementation was increased to 325mg po
tid, and she was started on B12.
3. atrial fibrillation - She was continued on coumadin, with INR
2.6. Metoprolol was continued for rate control, though she
refused it daily. Her HR remained below 100. She was monitored
on telemetry.
4. myasthenia - Mestinon, cellcept, prednisone continued during
the hospitalization without adjustment per her primary
neurologist.
PPx - treated with vitamin D, calcium, PPI, SSI, bactrim, MVI
Code status: DNR/DNI
Medications on Admission:
1. Prednisone 50 mg PO DAILY
2. Mycophenolate Mofetil 1000 mg PO BID
3. Calcium Carbonate 500 mg Tablet, Chewable PO BID
4. Cholecalciferol (Vitamin D3) 400 unit Two Tablet PO DAILY
5. Multivitamin,Tx-Minerals PO DAILY
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO DAILY
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
8. Pyridostigmine Bromide 30 mg PO TID
9. Docusate Sodium 100 mg Capsule PO BID
10. Senna 8.6 mg Tablet PO BID
11. Ipratropium Bromide 0.02 % Solution Inhalation Q6H
12. Pantoprazole 40 mg Tablet PO Q24H
13. Metoprolol Tartrate 25 mg PO BID; does not use this
14. Furosemide 20 mg PO DAILY
15. Coumadin 4-5 mg Tablet PO once a day
Discharge Medications:
1. orthotics
Please fit Ms. [**Known lastname 18806**] with bilateral splints for foot drop.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO TID (3 times a day).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
9. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. Cyanocobalamin 1,000 mcg/mL Solution Sig: 1000 (1000) mcg
Injection DAILY (Daily) for 5 days: then 1000mcg qweek x 4
weeks, then 1000mcg monthly.
18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulized
treatment Inhalation Q6H (every 6 hours) as needed for dyspnea.
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Dyspnea
Iron deficiecy anemia
Restrictive lung disease
Chronic obstructive pulmonary disease
Myasthenia [**Last Name (un) 2902**]
History of pulmonary emboli
Discharge Condition:
Stable; can count to 28 in one breath on the day of discharge,
which has been her baseline.
Discharge Instructions:
Take medications as prescribed. Please follow up at your
scheduled appointments.
Please call your doctor or go to the emergency room if you have
any worsening difficulty breathing, chest pain, nausea,
vomiting, increasing weakness, difficulty swallowing, or any
other concerning symptoms.
Followup Instructions:
Please follow up with these scheduled appointments:
Pulmonary:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3172**]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2113-10-4**] 10:00
GI:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST OFFICE (SB)
Date/Time:[**2113-9-27**] 1:00
Neurology:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2113-11-16**]
10:30
HEME:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2113-10-3**] 3:00
ICD9 Codes: 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4682
} | Medical Text: Admission Date: [**2185-10-11**] Discharge Date: [**2185-10-17**]
Date of Birth: [**2185-10-11**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 23200**] [**Known lastname **] is the
former 3.165 kg product of a 36 and [**5-5**] week gestation
pregnancy, born to a 35 year-old, G4, P2 now 3 woman.
Prenatal screens: Blood type A positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS positive. The pregnancy was uncomplicated
until the mother presented in preterm labor on the day of
delivery. She was to have a repeat Cesarean section. The
infant emerged with good respirations and cry. She was
evaluated for respiratory distress in the recovery room area,
status post Cesarean section and was admitted to the Neonatal
Intensive Care Unit for evaluation and treatment of
respiratory distress.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit revealed a weight of 3.165 kg, length 49
cm, head circumference 34 cm.
PHYSICAL EXAM AT DISCHARGE: Weight 2.98 kg, length 50.5 cm,
head circumference 34 cm. GENERAL: Alert, non distressed,
non dysmorphic female infant, room air. Skin warm and dry.
Color pink, slightly jaundiced. Head, ears, eyes, nose and
throat: Anterior fontanel open and flat. Sutures apposed.
Symmetric facial features. Palate intact. Neck supple.
Chest: Intact clavicles. Breath sounds clear and equal.
Easy respirations. Cardiovascular: Regular rate and rhythm.
No murmur. Normal S1 and S2. Femoral pulses +2. Abdomen
nontender, nondistended, no masses. Positive bowel sounds.
Cord on and drying. Genitourinary: Normal female external
genitalia. Musculoskeletal: Spine straight, normal sacrum.
Hips stable. Moving all. Normal digits, nails and creases.
Neurologic: Symmetric tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: System 1: Respiratory. This infant had significant
respiratory distress that was manifested by oxygen
requirement and respiratory acidosis. She was electively
intubated and received 2 doses of Surfactant. She was
extubated to room air late on the day of birth and has
continued in room air for the rest of her Neonatal Intensive
Care Unit admission. At the time of discharge, she is
breathing comfortably in room air with a respiratory rate of
30 to 60 breaths per minute, maintaining oxygen saturations
greater than 96%. She was monitored for 5 days after some
transitional desaturations noted when she initiated p.o.
feeds.
System 2: Cardiovascular. This infant has maintained normal
heart rates and blood pressures. No murmurs have been noted.
Baseline heart rate of 120 to 150 beats per minute with a
recent blood pressure of 63/35 mmHg. Mean arterial pressure
of 44 mmHg.
System 3: Fluids, electrolytes and nutrition. This infant
was initially n.p.o. and maintained on IV fluids. Enteral
feeds were started on day of life #1 and advanced to full
volume and have been well tolerated. She is taking Enfamil 20
calories per ounce formula with a minimum of 120 mm/kg per
day. Weight on the day of discharge is 2.98 kg. Serum
electrolytes were checked at 24 hours of life and were within
normal limits.
System 4: Infectious disease. Due to her respiratory
distress, this infant was evaluated for sepsis upon admission
to the Neonatal Intensive Care Unit. A white blood cell
count and differential were within normal limits. A blood
culture was obtained prior to starting IV ampicillin and
gentamycin. The blood culture was no growth at 48 hours and
the antibiotics were discontinued.
System 5: Hematologic. Hematocrit at birth was 50%. This
infant is blood type 0 positive and is direct antibody test
negative. She did not receive any transfusions of blood
products.
System 6: Gastrointestinal. Peak serum bilirubin occurred
on day of life 4. Total of 13 mg/dl. Repeat on day of life
5 was 12 mg/dl.
System 7: Neurologic. This infant has maintained a normal
neurologic exam during admission. There were no neurologic
concerns at the time of discharge.
System 8: Sensory.
Audiology: Hearing screening was performed with automated
auditory brain stem responses--Passed
System 9: Psychosocial. This is a mandarin speaking Asian
family. The [**Hospital1 69**] social
worker involved with this family is [**Name (NI) 46381**] [**Last Name (un) 40476**]-[**Doctor Last Name **] and
she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Through [**Hospital3 29903**], [**State 73668**], [**Location (un) 86**], [**Numeric Identifier 53855**]. Phone
number [**Telephone/Fax (1) 8236**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Ad lib p.o. feeding Enfamil 20 calorie per
ounce formula.
2. No medications.
3. 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 i.u. (may be provided
as a multi-vitamin preparation) daily until 12 months
corrected age.
4. Car seat position screening was performed. This infant
was observed in the car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
5. State newborn screen was sent on [**2185-10-14**] and
[**2185-10-17**]. There has been no notification of abnormal
results to date.
6. Immunizations:
Hepatitis B vaccine was administered on [**2185-10-15**].
1. 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 weeks 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; (3)
chronic lung disease or (4) hemodynamically significant
congenital 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.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Preterm infant at 36 and 6/7 weeks gestation.
2. Respiratory distress syndrome secondary to Surfactant
deficiency.
3. Suspicion for sepsis ruled out.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2185-10-17**] 02:18:09
T: [**2185-10-17**] 05:19:33
Job#: [**Job Number 76128**]
ICD9 Codes: V053, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4683
} | Medical Text: Admission Date: [**2187-6-21**] Discharge Date: [**2187-7-2**]
Date of Birth: [**2162-7-10**] Sex: M
Service:
ILLNESS: Rectal perforation.
HISTORY OF PRESENT ILLNESS: The patient is a 24 year old
male who presented to the emergency department with 24 to 48
hours of lower abdominal pain. He was seen in another
facility, and then transferred here, hypotensive and
tachycardic with a CT scan suggesting a rectal perforation.
PHYSICAL EXAMINATION: The patient appeared ill, had a
temperature of 102. Abdomen was tender with guarding.
HOSPITAL COURSE: The patient was taken to the operating
room. The perforation could not be repaired. A proximal
colostomy was performed. Postoperatively the patient was in
the intensive care unit for several days, but was treated
with IV antibiotics and appropriate fluid. He then began to
progress and was changed to a diet. He began rehab screening
which took several days. He was counseled with enterostomal
therapy and was discharged on [**7-2**].
DISCHARGE MEDICATIONS:
1. Percocet po q.4h p.r.n.
2. Metamucil.
DISCHARGE PLAN: Return to clinic to see Dr. [**Last Name (STitle) **] in 2
weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 16475**]
MEDQUIST36
D: [**2187-9-6**] 13:11:41
T: [**2187-9-6**] 14:41:08
Job#: [**Job Number 62191**]
ICD9 Codes: 0389, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4684
} | Medical Text: Admission Date: [**2141-6-19**] Discharge Date: [**2141-6-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
blood transfusion
History of Present Illness:
The patient is an 81 year old male with a history of CAD status
post CABG times x4 and ICD, atrial fibrillation on coumadin,
hypertension, diabetes type I, and CHF who presented to [**Hospital **]
Hospital on [**6-19**] as the patient noticed that his ICD had fired x
2 in the past 24 hours. At the OSH, the patient was noted to
have a Hct of 30 with BUN/Cr of 100/2.2. His baseline Hct is 38.
He then reported that he had noticed 3 days of black, tarry
loose stool. He has never had gastrointestinal bleeding nor has
he had a prior colonoscopy. He denied any bright red blood per
rectum, hematemesis, nausea or vomiting.
He was transferred to the [**Hospital1 18**] as he receives cardiac care
here. In the ED, he was found to have a Hct of 32.4 with a
positive NG lavage that did not clear (by report) and an INR of
2.2. His Cr was 2.1 (baseline 1.1-1.5), WBC of 13 with 78% PMNs.
His HR was 116, SBP 134/57 after 250 cc IVF at the OSH. He was
reported as being 88/51 en route to [**Hospital1 18**].
In the ED, the patient received 4 units FFP, 2 units PRBC with
40 IV lasix between units, 10 mg SC Vitamin K and 40 mg IV
protonix. GI and EP evaluated the patient in the ED. EP
increased his set rate for his ICD to 150-160 bpm and felt his
ICD was otherwise working well but was set off from his rapid
afib with widened QRS. GI planned for EGD when INR reversed.
Past Medical History:
1. DMI, for 30 years c/b neuropathy
2. CAD: s/p Cath ([**2128**]) with clean coronary arteries, ETT
Persantine study ([**12-21**]) with fixed, and Cath ([**2-22**]) with distal
RCA 60% lesion, left main 30% discrete lesion, mid LAD 90%, D1
80%, proximal circ 80%,
OM1 70% and wedge of 17 s/p 4v-CABG ([**2-22**]) with LIMA to LAD,
vein graft to PDA, vein graft to OM1 and radial artery to diag
3. CHF, EF 30% s/p ICD for primary prevention of sudden cardiac
death (did not place [**Hospital1 **]-v ICD because QRS duration was under 120
msec)
4. Chronic AF, asymptomatic, ICD interrogated by [**Doctor Last Name **] [**3-25**]
and showed an isolated episode of atrial fibrillation with a
rapid ventricular response in his ventricular tachycardia zone
5. Right ICA stenosis > 70%, asymptomatic
6. HTN
7. s/p removal of malignant bladder tumor
8. Gout
9. Varicose veins
10. CABG complicated by mediastinitis treated with antibiotics.
The patient left AMA from that hospitalization
Social History:
Patient lives with his wife. [**Name (NI) **] has two
children, a daughter who is a nurse. He is retired post
office worker. He quit smoking 30 years ago and does not
drink alcohol.
Family History:
Father died of an MI at 60, his brother had
a CABG at age 60 and his other brother an MI at age 70.
Physical Exam:
Tc = 96.5 P=97 BP=181/72 RR=16 100% on NC
Gen - NAD, AOX3, slow to answer questions but answers
appropriately
HEENT - Mildly pale conjuctiva, anicteric, dry MMM
Heart - Irregular, Grade II/VI SEM throuhout precordium best
heard at RUSB with bilateral carotid bruits
Lungs - CTAB
Abdomen - Soft, NT, ND, + BS
Ext - Chronic venous stasis dermatitis near ankles bilaterally
with +1 d. pedis bilaterally, trace edema bilaterally
Skin - Multiple seborrheic keratoses on back/chest
Pertinent Results:
CXR [**2141-6-19**]: Stable cardiomegaly. No CHF or pneumonia.
EKG [**2141-6-9**]: Afib with LBBB, LVH, TWI I, avL, [**Street Address(2) 1766**] elevations
with LBBB discordant with QRS
[**2141-6-19**] 09:59PM GLUCOSE-170* UREA N-119* CREAT-1.7*
SODIUM-142 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2141-6-19**] 09:59PM ALT(SGPT)-17 AST(SGOT)-23 LD(LDH)-160 ALK
PHOS-52 AMYLASE-76 TOT BILI-0.4
[**2141-6-19**] 09:59PM LIPASE-46
[**2141-6-19**] 09:59PM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.9#
MAGNESIUM-2.0 CHOLEST-129
[**2141-6-19**] 09:59PM TRIGLYCER-277* HDL CHOL-29 CHOL/HDL-4.4
LDL(CALC)-45
[**2141-6-19**] 07:52PM HCT-28.0*
[**2141-6-19**] 07:52PM PT-17.5* PTT-28.1 INR(PT)-2.0
[**2141-6-19**] 01:20PM GLUCOSE-195* UREA N-138* CREAT-2.1*
SODIUM-141 POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-21* ANION
GAP-20
[**2141-6-19**] 01:20PM WBC-13.0* RBC-3.52*# HGB-11.1*# HCT-32.4*#
MCV-92 MCH-31.6 MCHC-34.3 RDW-14.5
[**2141-6-19**] 01:20PM NEUTS-78.4* LYMPHS-18.3 MONOS-2.7 EOS-0.5
BASOS-0.2
[**2141-6-19**] 01:20PM PLT COUNT-191
[**2141-6-19**] 01:20PM PT-18.3* PTT-27.2 INR(PT)-2.2
Brief Hospital Course:
The patient is an 81 year old male with a history of CAD s/p
CABG, ICD with afib on coumadin, and DMII who presented with
melenotic stools and a 8 point Hct drop from baseline with rapid
afib.
1. UGIB; received a total of 3 Units of PRBC's. Hct now stable.
- The patient underwent an EGD on [**6-19**] that showed a gastric
ulcer in the proximal body of the stomach that proved to be the
source of his UGIB. In addition, there was a visible clot in the
distal esophagus. There were ulcers in the stomach but not the
duodenum. The crater in the proximal stomach was injected with
epinephrine and cauterized. GI suggests that if Hct remains
stable, he return for another EGD in [**6-28**] weeks to re-evaluate
healing of the current gastric ulcers and question the utility
of a biopsy to assess for possible malignancy.
- He was found to have H. pylori and started on a 2 week course
of therapy with protonix, clarithromycin, and azithromycin.
- He was initially kept NPO, however his diet was advanced as
tolerated once hct was stable.
2. Afib s/p ICD
- The patient was taking coumadin 5 mg as an outpatient with a
goal INR [**2-23**]. On admission he was given Vitamin K 10 mg SQ x 1
and FFP for reversal of an initial INR of 2.2. His coumadin was
held during his stay however was restarted at discharge.
- He was discharged on Toprol XL 150 mg for rate control
- His digoxin was continued
- The patient had a St. [**Male First Name (un) 923**] ICD placed for primary prevention
of sudden cardiac death given his ischemic cardiomyopathy. His
ICD has been evaluated by EP on [**6-19**] and felt to be working
effectively. It was most likely triggered by the rapid
ventricular rate in the setting of afib with a baseline LBBB.
3. DMI. His oral meds were initially held while he was NPO. He
was covered with a SSI while he is hospitalized His glyburide 6
mg and Metformin 500 mg [**Hospital1 **] were restared prior to discharge.
4. HTN
- The patient takes Toprol XL 150 mg and Zestril 40 mg at home.
His BP remained stable throughout his stay and his oupatient
anti-HTN medications were restarted.
5. CHF, EF 30%
- He was given maintenance fluids while kept NPO with lasix
between blood transufions. He was discharged home on Lasix 40
mg [**Hospital1 **].
6. Acute on chronic renal failure (baseline Cr 1.3-1.5). Cr
improved to 1.5 from 2.1 with IV hydration.
- Most likely pre-renal in nature in the setting of loose stools
with melena in the past few days.
7. CAD
- Discharged home on Bblocker and ACE. His ASA was held given GI
bleed.
- lipid profile WNL, pt does not need statin (LDL 45).
8. CODE: DNR but agrees to resuscitation including CPR and
defibrillation (he has an ICD in place). We discussed how this
is difficult to respect as protecting one's airway and
protecting their heart in an emergency are both necessary for
complete CPR but he reiterated his desire not to be intubated
but agrees to resuscitation.
Medications on Admission:
Metformin 500 [**Hospital1 **]
Lasix 40 [**Hospital1 **]
glyburide 6mg daily
Toprol XL 150
allopurinol 5 mg QD
Zestril 40
Digetek .125
Aspirin 81
Coumadin 5 mg
Discharge Medications:
1. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 1 doses.
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day:
except sunday.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: pantoprazole is
available over the counter or as a generic.
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Glyburide 1.25 mg Tablet Sig: Four (4) Tablet PO twice a
day.
12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed secondary to peptic ulcer disease
H. pylori induced peptic ulcer disease
Discharge Condition:
stable and improved
Discharge Instructions:
Please seek immediate medical attention if you experience fever
greater than 101, shaking chills, lightheadedness, palpitations,
chest pain, or have black/tarry stools, or bloody stools.
Please resume your other home medications except please do not
take aspirin. You are on a 2 week course of therapy for
treatment of H. pylori (protonix, clarithromycin, azithromycin).
Followup Instructions:
1. Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks.
2. Please have your blood work checked on Monday and have the
results sent to your PCP.
3. Please follow up with Dr. [**Last Name (STitle) **] in GI to obtain a repeat
endoscopy in [**6-28**] weeks. Call ([**Telephone/Fax (1) 8892**] to make a clinic
appointment.
ICD9 Codes: 4280, 5849, 2851, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4685
} | Medical Text: Admission Date: [**2139-4-1**] Discharge Date: [**2139-4-20**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
[**Age over 90 **]F PMH COPD, diastolic CHF, admission for ORIF of left femur fx
complicated by LLE DVT [**5-/2138**], brought in by ambulance f/NH for
hypoxia and hypotension. Labs at NH showed leukocytosis 22k, cr
1.3, inr 6.7. DFA+ at rehab, started tamiflu, ctx, levoflox,
transferred to [**Hospital1 18**].
In [**Hospital1 18**] ED, vs 97.7, 131, 88/46, 100%NRB. Noted to have
systolics to the 70s, improved to 90s with 2L NS, initiated on
levophed gtt, then transitioned to off. EKG showed afib-rvr.
Vancomycin and cefepime initiated for HAP, given combivent nebs,
femoral line placed, given 2L NS. Cards evaluated, believes
trop 0.23 suggestive NSTEMI. Cardiology outpt attending
notified, suggested metoprolol vs amiodarone, given adenosine
6mg, then 12mg with transient slowing. SBP 90s, HR 90s.
Code status confirmed in ED to be DNR/DNI but yes to pressors
- confirmed with daughter/POA.
Past Medical History:
1. Type 2 Diabetes
2. Hypertension
3. Osteopenia
4. Nasopharyngeal cancer ([**2122**])
5. COPD
6. s/p right distal femoral fracture and right hip fracture in
[**10/2134**], no intervention
7. s/p left distal femoral fracture in [**5-/2138**] with ORIF and
subsequent LLE DVT
8. diastolic CHF (LVEF >75%) with moderate MR/TR
Social History:
currently a resident at [**Hospital 100**] Rehab and has been bedbound since
[**2134**]. She is widowed x 35 years. She smoked previously, quitting
in [**2132**]. She is a retired real estate broker. She has two
daughters - [**Name (NI) **] who resides in CT and [**Name (NI) **] who lives in
[**Location (un) 55**].
Family History:
mother died at 69 of unknown cause. Father died at 80 of unknown
cause. Two daughters in their 60's, both healthy.
Physical Exam:
Admission PE
T 97.5 BP 110/70 on levo HR 95 RR 20 99%2L
Gen - mild distress, mild resp distress with acessory muscles,
complaining of "not feeling well."
HEENT - anicteric sclera, mildly dry membranes
Heart - s1+s2+ irregular no murmurs, tachy
Lungs - decreased effort
Abdomen - distended, obese
Extremities - +edema, r fem line with bandage and oozing
.
Discharge PE
PE - T BP HR RR 96%3L Tele- sinus rhythm w/frequent PVCs,
occasionally afib
Gen/Neuro - elderly woman with NGT in place, minimally
responsive, opens eyes and turns head to voice, moving LUE
extremity only, responds to pain, does not follow commands,
appears comfortable. R facial droop.
HEENT - anicteric sclera, MMM OP clear, no [**Doctor First Name **], NG tube in place
Heart - s1+s2+ regular, no murmurs, no JVD
Lungs - CTA anteriorly and laterally
Abdomen - soft, +BS, mildly distended, obese
Extremities - +edema/ecchymoses in upper extremities, no edema
in LEs
Pertinent Results:
ADMISSION LABS:
.
[**2139-4-1**] 12:00PM GLUCOSE-256* UREA N-52* CREAT-1.3* SODIUM-141
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12
[**2139-4-1**] 12:00PM WBC-21.0*# RBC-4.08* HGB-12.4 HCT-38.2 MCV-94
MCH-30.3 MCHC-32.4 RDW-14.2
[**2139-4-1**] 12:00PM NEUTS-93.9* BANDS-0 LYMPHS-3.8* MONOS-2.0
EOS-0.1 BASOS-0.2
[**2139-4-1**] 12:00PM PT-60.3* PTT-55.3* INR(PT)-7.2*
[**2139-4-1**] 12:46PM BLOOD pO2-184* pCO2-52* pH-7.39 calTCO2-33*
Base XS-5 Comment-GREEN TOP
[**2139-4-1**] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2139-4-1**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2139-4-1**] 01:15PM URINE RBC-[**4-15**]* WBC-[**7-21**]* BACTERIA-MOD
YEAST-FEW EPI-0-2
[**2139-4-1**] 08:51PM CK(CPK)-108
[**2139-4-1**] 08:51PM CK-MB-14* MB INDX-13.0* cTropnT-0.34*
.
OTHER LABS
[**2139-4-5**] 04:29AM BLOOD ALT-33 AST-20 LD(LDH)-256* AlkPhos-121*
Amylase-33 TotBili-0.5
[**2139-4-11**] 06:35AM BLOOD WBC-17.4* RBC-3.59* Hgb-11.1* Hct-33.5*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-276
[**2139-4-11**] 06:35AM BLOOD PT-13.5* PTT-37.8* INR(PT)-1.2*
[**2139-4-11**] 06:35AM BLOOD Glucose-270* UreaN-19 Creat-0.4 Na-141
K-4.3 Cl-97 HCO3-36* AnGap-12
[**2139-4-15**] 09:45AM BLOOD WBC-11.8* RBC-3.59* Hgb-11.1* Hct-34.6*
MCV-96 MCH-30.8 MCHC-32.1 RDW-14.5 Plt Ct-325
[**2139-4-16**] 06:30PM BLOOD PT-12.4 PTT-25.1 INR(PT)-1.0
[**2139-4-15**] 09:45AM BLOOD Glucose-139* UreaN-14 Creat-0.4 Na-141
K-4.6 Cl-97 HCO3-39* AnGap-10
[**2139-4-15**] 09:45AM BLOOD ALT-32 AST-44* LD(LDH)-355* AlkPhos-87
TotBili-0.4
[**2139-4-3**] 05:49AM BLOOD CK(CPK)-46
[**2139-4-2**] 04:03AM BLOOD CK(CPK)-92
[**2139-4-1**] 08:51PM BLOOD CK(CPK)-108
[**2139-4-1**] 12:00PM BLOOD CK(CPK)-86
[**2139-4-3**] 05:49AM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2139-4-2**] 04:03AM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2139-4-1**] 08:51PM BLOOD CK-MB-14* MB Indx-13.0* cTropnT-0.34*
[**2139-4-1**] 12:00PM BLOOD cTropnT-0.23*
[**2139-4-15**] 09:45AM BLOOD Albumin-3.1* Calcium-9.4 Phos-3.6 Mg-2.1
[**2139-4-10**] 06:50AM BLOOD Triglyc-109 HDL-46 CHOL/HD-2.2 LDLcalc-31
[**2139-4-9**] 02:29PM BLOOD %HbA1c-6.8*
[**2139-4-1**] 08:55PM BLOOD Glucose-116* Lactate-1.0 calHCO3-29
.
STUDIES
CXR [**2139-4-1**]-IMPRESSION: No acute cardiopulmonary abnormalities.
CXR [**2139-4-4**]-IMPRESSION: AP chest compared to [**4-2**] and
22: Moderate cardiomegaly is chronic, small bilateral pleural
effusions have increased, pulmonary vascular congestion in the
upper lungs persists, but there is no pulmonary edema. No
pneumothorax.
CXR [**2139-4-5**]-IMPRESSION:AP chest compared to [**4-1**] through
23: Severe cardiomegaly is longstanding. Small-to-moderate left
pleural effusion stable since [**4-4**]. Pulmonary vascular
engorgement suggests a mild-to-moderate cardiac decompensation.
Left lower lobe opacification can be
explained by atelectasis present since at least [**4-1**].
Right lung shows no evidence of pneumonia. No pneumothorax.
Nasogastric tube passes into the stomach and out of view.
CHEST (PORTABLE AP) [**2139-4-14**] 11:18 PM
1. The right upper lobe airspace disease is almost cleared
indicating either it was edema or atelectasis.
2. Persistent bilateral bibasilar atelectasis with small
coexistent pleural effusion. The homogeneous opacification in
the left lung could be attributed to patient's body habitus and
positioning during the procedure.
.
ECHO [**5-18**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA mod dilated. LV wall
thicknesses nl. LV hyperdynamic (EF>75%). MV leaflets mildly
thickened. Mild to mod ([**2-11**]+) MR, mod [2+] TR. Mod pulm artery
systolic htn.
.
CT Head [**2139-4-4**] IMPRESSION: Probable large left MCA ischemia. CT
perfusion or MRI are recommended for further characterization.
.
CT Head [**2139-4-7**] (Prelim): There is now marked diffuse
hypodensity seen throughout the left MCA territory, consistent
with evolution of large left MCA territory infarct. There is no
sign of intracranial hemorrhage. There is now mild regional
sulcal effacement, as well as a small amount of mass effect on
the frontal [**Doctor Last Name 534**] of the left lateral ventricle. The ventricles
are otherwise unchanged in size and the basal cisterns are not
effaced.
IMPRESSION: Evolving large left MCA territory infarct, now with
mild regional sulcal effacement, and minimal mass effect on the
frontal [**Doctor Last Name 534**] of the left lateral ventricle
.
MICROBIOLOGY
[**2139-4-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2139-4-15**] Direct Antigen Test for Herpes Simplex Virus Types 1
& 2 Direct Antigen Test for Herpes Simplex Virus Types 1 &
2-FINAL NEG; DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER
VIRUS-FINAL NEG; VARICELLA-ZOSTER CULTURE-PENDING
TAN-[**Last Name (LF) 61435**],[**First Name3 (LF) **] K.
[**2139-4-15**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, [**Female First Name (un) **] ALBICANS,
PRESUMPTIVE IDENTIFICATION}; POTASSIUM HYDROXIDE
PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **] ALBICANS,
PRESUMPTIVE IDENTIFICATION} TAN-[**Last Name (LF) 61435**],[**First Name3 (LF) **] K.
[**2139-4-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2139-4-8**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-4**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT NEG
[**2139-4-2**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-1**] SWAB VIRAL CULTURE-PENDING INPATIENT NEG
[**2139-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2139-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
Brief Hospital Course:
Patient is a [**Age over 90 **] year old woman with past medical history of
COPD, diastolic CHF, ORIF of left femur fracture complicated by
left lower extremity DVT in [**5-/2138**], who was brought in by
ambulance from nursing home for hypoxia and hypotension,
initially admitted to ICU for septic shock, eventually
transferred to the floors when hemodynamically stable. Hospital
course by problem:
.
# Influenza/?Pneumonia/sepsis: Patient presented from nursing
home in respiratory distress, hypotensive, initially requiring a
non-rebreather, and pressor therapy after IVF resuscitation.
CXR on admission demonstrated evidence of retrocardiac opacity.
Per report from nursing home, DFA swab sent just prior to
transfer ended up positive for influenza. The patient was
treated for influenza with 5 days of tamiflu, and was initially
on vancomycin/cefepime for pneumonia, which was converted to
levofloxacin to complete a 7 day course. As above, she was
started on pressor support on admission due to
hypotension/sepsis, also with initial lactate of 2.7, but was
quickly weaned off pressors with IVF support with good
maintenance of blood pressure. Lactate normalized. As below,
the patient was noted to be in atrial fibrillation with RVR on
admission which was thought to explain her hypotension rather
than an infectious sepsis etiology. This was managed as
described below.
.
# Acute stroke: The patient developed acute MS changes early AM
on [**4-4**], with apparent right sided neglect on exam. Code stroke
was called, a CT head (without contrast) was obtained which
demonstrated a large left MCA territory stroke, embolic.
Neurology was involved and recommended no TPA given the
patient's age and co-morbidity, and recommended no need to check
an ECHO or carotid ultrasound as it would not change management.
She was maintained on a beta blocker for blood pressure
control, with IV hydralazine PRN to keep SBP < 160. She was
also started on a statin. Neurology followed along during
hospital course and felt she likely had a poor prognosis given
her age. The patient remains non-verbal without use of right
side. A repeat CT showed evolving area of infarct but no
evidence of bleed. A family meeting was held when she was on the
general medicine floor (on [**2139-4-10**] with the neurology team,
palliative care team, and primary geriatric team to discuss
goals of care. The family is still uncertain about goals of care
but determined she would not want any invasive procedures (PICC,
TEE, MRI, frequent lab draws) at this point. They would like a
couple of weeks to observe her progress and reassess her goals
of care. She was continued on metoprolol for blood pressure
control (with prn hydralazine through the NG tube) and was given
lovenox (as opposed to coumadin) for anticoagulation to avoid
need for frequent lab draws. If the family decides to pursue a
more aggressive management, neuro made the following
recommendations: obtain TTE and duplex carotids, keep LDL<70,
check HgA1c, start coumadin and get MRI head to evaluate extent
of damage.
.
# Cardiac:
A. CHF: The patient has a history of diastolic dysfunction, and
was on losartan and metoprolol during the hospital course. In
the ICU she had had recurrent problems with episodes of
hypertension leading to desaturation/wheezing, requiring tight
blood pressure and volume status control. She received IV
hydralazine PRN, IV lasix to maintain negative fluid balance.
Losartan was discontinued due to stroke above, and her blood
pressure was managed with a goal BP 140-160, and close
monitoring of volume status. On the floors she was continued on
metoprolol with po hydralazine prn to keep blood pressure within
goal range.
.
B. Rhythm: The patient was initially in atrial fibrillation on
presentation (no history of atrial fibrillation per records),
then was in normal sinus rhythm during her early hospital
course. She went back in atrial fibrillation with rapid
ventricular response in the setting of acute stroke - at that
time, she received dig load in attempt to maintain blood
pressure, but she was not continued on dig. She was maintained
on metoprolol, low dose, and spontaneously converted back to
normal sinus rhythm within 24 hours. She was not started on
coumadin for fear of converting her large ischemic stroke into a
hemorrhagic stroke. Once the repeat Head CT came back negative
for hemorrhage there was discussion of restarting her on
coumadin but the family declined as this would require frequent
blood sticks for monitoring INR and she had very poor access.
She was started on SC lovenox instead. On the floors her rate
was well-controlled on metoprolol though for her rhythm she did
go in and out of NSR and a-fib.
.
# UTI: The patient presented as above, and the u/a in ED was
positive, though no cultures were sent at that time. Repeat u/a
after 24hrs of antibiotics was negative, and culture was
negative. She completed a 7 day course of levofloxacin.
.
#. Respiratory distress overnight on [**4-14**]: The patient triggered
for hypoxia and respiratory distress, was felt to be volume
overloaded v. aspiration and received 40mg po lasix and 25mg po
hydral. She diuresed 3 L and her O2 sat improved from requiring
6LO2 to her baseline 3L O2 requirement. She looked very
comfortable the next day w/some crackles on exam so she was
given another 40mg po lasix. She subsequently appeared euvolemic
and comfortable. She had PEG placed given risk for aspiration.
She has been on aspiration precautions. I/O should be closely
monitored.
.
Rash- The patient developed linear lesions with pustules on R
scapula with a few satelite lesions on L. Could be pustular
zoster though DFA was negative (culture pending). Derm was
consulted, she was put on zoster precautions and treated with 7
days of acyclovir 500mg 5x/day per NGT for 7 days total (started
[**2139-4-13**]), finished today [**4-20**]. Please follow up viral culture and
monitor clinically for signs of further dissemination (has had
none in house).
# History of DVT: The patient has a history of DVT in [**5-18**] in
the setting of a surgical procedure in [**5-18**]. She was on
coumadin as an outpatient, and presented supratherapeutic, so
coumadin was held. FFP was administered on the day after
admission in order to reverse coumadin to remove the femoral
line. Coumadin was not restarted initially because the patient
was status post 6 months of treatment.
.
# Diabetes mellitus II: The patient was maintained on an
insulin sliding scale. 25 units lantus qhs was added for optimal
control. This can be titrated up as necessary.
.
# Renal failure: Cr elevated at 1.3 on admission, resolved
with IVF.
.
# Access: Patient had difficult peripheral access, but
patient's family did not want PICC or central line placed, so
she currently has no IV access.
.
# FEN: Patient was initially on regular diet, then after
stroke as above, had NGT placed and subsqeuently a PEG placed.
She is receiving tube feeds. The family needs to discuss goals
of care as discussed above.
.
# Code - DNR/DNI (yes to pressors)
Medications on Admission:
1. Warfarin 1.5mg qd
2. Escitalopram 10mg qd
3. Trazodone 50mg qhs
4. Losartan 50mg qd
5. Metoprolol Tartrate 12.5mg [**Hospital1 **]
6. Pantoprazole 20mg qd
7. Aspirin 81mg qd
8. Hexavitamin qd
9. Ipratropium Bromide 0.02 q4hrs
10. Albuterol Sulfate 0.083 q4hrs
11. Senna 8.6mg [**Hospital1 **]
12 Docusate Sodium 100mg [**Hospital1 **]
13. Cyanocobalamin 1,000 mcg qmonth
14. Glipizide 10mg [**Hospital1 **]
15. ISS
16. Cholecalciferol (Vitamin D3) 400u qd
17. Calcium Carbonate 500mg tid prn
Discharge Medications:
1. Influenza Tri-Split [**2138**] Vac 45 mcg/0.5 mL Suspension [**Year (4 digits) **]:
0.5 ML Intramuscular ASDIR (AS DIRECTED).
2. Ferrous Sulfate 300 mg/5 mL Liquid [**Year (4 digits) **]: Five (5) mL PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Year (4 digits) **]: 2.5 Tablets
PO DAILY (Daily).
4. Citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet [**Year (4 digits) **]: 0.5 Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable [**Year (4 digits) **]: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Aspirin 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2
times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast infection.
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
Three (3) mL Inhalation Q4H (every 4 hours).
14. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day): Hold for HR<55, SBP<100.
15. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours).
16. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
TID (3 times a day) as needed for constipation.
17. Enoxaparin 40 mg/0.4 mL Syringe [**Hospital1 **]: Forty (40) mg
Subcutaneous DAILY (Daily).
18. Lantus 100 unit/mL Cartridge [**Hospital1 **]: Twenty Five (25) units
Subcutaneous at bedtime: MD [**First Name (Titles) **] [**Last Name (Titles) **] up as needed.
19. Insulin Regular Human 100 unit/mL Cartridge [**Last Name (Titles) **]: as directed
as directed Injection every six (6) hours:
Glucose/ Insulin
0-50 mg/dL/ 4 oz. Juice; 51-150 mg/dL/ 0 Units;
151-200 mg/dL/ 3 Units; 201-250 mg/dL/ 6 Units;
251-300 mg/dL 9 Units; 301-350 mg/dL/ 12 Units ;
351-400 mg/dL/ 15 Units ;
> 400 mg/dL Notify M.D.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary
1. Non ST elevation myocardial infarction
2. Atrial fibrillation with rapid ventricular rate, currently
rate-controlled
3. Left MCA stroke with Right-sided hemiplegia
4. Leukocytosis of unknown etiology
5. Acute bronchitis
6. Acute renal failure
7. Pustular R scapula infection, possibly zoster
Secondary:
1. Chronic diastolic congestive heart failure
2. Diabetes mellitus
Discharge Condition:
R-sided hemiparesis, awakes and moves head and eyes to voice.
Mumbles some incoherent words. Moves L arm. PEG tube for
feeding. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you were hypoxic and
hypotensive. You suffered from a heart attack (NSTEMI) and
developed atrial fibrillation with rapid ventricular rate. You
were treated in the ICU because you were clinically unstable.
You were treated with metoprolol and coumadin for your atrial
fibrillation. You also completed a course of antibiotics for
pneumonia and UTI, and tamiflu for presumptive flu. During your
hospitalization you had a stroke which likely occurred when you
converted from atrial fibrillation to normal sinus rhythm.
Neurology was consulted. Your coumadin was stopped and you were
started on aspirin. Although a repeat Head CT indicated you did
not have a bleed with the stroke, you were not restarted on
coumadin because you did not have IV access and your family
decided they did not want to monitor INR in order to spare you
from needing a PICC or frequent blood draws. A family meeting
was held and your family is still unsure of whether they want to
begin a stroke work-up or stroke prevention medications. You are
receiving nutrition via a PEG tube. Your white count was
elevated but no source of infection was found. We stopped
monitoring your WBC as you remained afebrile with stable vital
signs and your family wishes to minimize blood draws. You also
developed a rash that was evaluated by dermatology and felt to
be consistent with zoster. You completed a 7 day course of
acyclovir (end date [**2139-4-20**]). Dermatology also noted a lesion
on your skin that could be consistent with SCC. Your family may
decide to pursue this further by making an appointment with the
dermatologists (see below).
.
Please continue to take medications as prescribed.
.
If the patient develops fever, chills, difficulty breathing,
hypotension, hypertension or other concerning symptoms please
call the doctor.
Followup Instructions:
Please make an appointment with PCP ([**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Telephone/Fax (1) 38919**]) if the patient is discharged from rehab.
.
Please make an appointment at the [**Hospital1 18**] neurology clinic ([**Telephone/Fax (1) 8951**] if the patient's family decides to pursue more
aggressive stroke work-up and management.
.
If the family wishes to pursue evaluation of a possible SCC,
please call the dermatology clinic at [**Hospital1 18**] and make a follow up
appointment ([**Telephone/Fax (1) 8132**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
Completed by:[**2139-4-20**]
ICD9 Codes: 0389, 5990, 5849, 496, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4686
} | Medical Text: Admission Date: [**2189-9-2**] Discharge Date: [**2189-9-17**]
Date of Birth: [**2144-6-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Lisinopril / Ace Inhibitors
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2189-9-3**] renal transplant
[**2189-9-16**] Tunnelled HD line
History of Present Illness:
45 y.o. M with ESRD who presents for renal transplant. He has no
recent h/o infections or interval changes in health. He has had
no fever/chills, nausea, vomiting, change in bowel habits,
travel outside of country, exposure to sick contacts. [**Name (NI) **] has not
had any recent changes in his medication regimen and was
dialyzed this am where they removed approx 4-4.5 liters. He
takes a daily 81mg ASA tab which he did not take today. Past
history is significant for CAD, MI with CABG and was cleared by
cardiology for transplant. He has been npo since 10am.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction, End-Stage
Renal Disease on Hemo-dialysis, Hypertension, GERD
Hypercholesterolemia, HIV+, Asthma, Gastroesophageal Reflux
Disease, Neuropathy, Lung nodules, Anemia, +VRE in past, s/p
Appendectomy, s/p Tonsillectomy, s/p Tracheostomy x 2, h/o Deep
Vein Thrombosis, Hyperparathyroidism, Anal HPV,
PSH: CABG, appy, tonsillectomy, R AVF, HD catheter placements
Social History:
Attorney. Lives with roommates. Has a partner. Quit smoking 6
years ago. Drinks a glass of wine on occasion. Denies drug use.
Family History:
CAD in many relatives but not at a young age.
Physical Exam:
A&O, pleasant, cooperative, NAD
HEENT: sclera non-icteric/non-injected, eomi/perrl, mmm,
oropharynx clear
Resp: coarse BS with wheezes on upper lung fields bilaterally,
no crackles/rubs, R tunnelled HD catheter. Site c/d/i
CV: RRR, no murmurs
ABD: S/NT/ND, BS +, obese, small umbilical hernia
Ext: no clubbing, venous stasis disease bilateral lower
extremities, no apparent lesions/ulcers, 2+ edema bilateral
lower extremities
Pertinent Results:
[**2189-9-16**] 06:40AM BLOOD WBC-6.2 RBC-2.52* Hgb-8.1* Hct-23.8*
MCV-95 MCH-32.1* MCHC-33.9 RDW-16.5* Plt Ct-255
[**2189-9-17**] 06:20AM BLOOD PT-12.8 PTT-24.9 INR(PT)-1.1
[**2189-9-15**] 06:00AM BLOOD Glucose-143* UreaN-79* Creat-8.9*# Na-133
K-4.7 Cl-95* HCO3-23 AnGap-20
[**2189-9-16**] 06:40AM BLOOD Glucose-110* UreaN-94* Creat-10.5*#
Na-133 K-5.0 Cl-96 HCO3-23 AnGap-19
[**2189-9-17**] 06:20AM BLOOD Glucose-112* UreaN-105* Creat-11.1*
Na-132* K-5.5* Cl-95* HCO3-20* AnGap-23*
[**2189-9-14**] 07:04AM BLOOD ALT-22 AST-17 AlkPhos-67 TotBili-0.4
[**2189-9-17**] 06:20AM BLOOD Calcium-8.5 Phos-8.8* Mg-2.5
[**2189-9-16**] 06:40AM BLOOD calTIBC-238* Ferritn-592* TRF-183*
[**2189-9-2**] 05:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2189-9-15**] 06:00AM BLOOD tacroFK-11.0
[**2189-9-16**] 06:40AM BLOOD tacroFK-13.9
Brief Hospital Course:
On [**2189-9-2**] he received a cadaveric renal transplant from a high
risk donor (given social history of donor. Discussed with
recipient)placed in the right retroperitoneum. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Induction immunosuppression consisted of cellcept,
solumedrol and ATG (usually simulect given per HIV/transplant
protocol), but due to higher PRA of 38%, he received ATG 150mg
intraop. The case was difficult due to the patients size. Please
see operative report for complete details. The kidney pinked up
and made a small amount of urine. The kidney was biopsied and
bled a significant amount. Stasis was achieved with Argon. There
was a small subcapsular hematoma. Postop in PACU he was
hypotensive, tachycardic and unable to be extubated and
transferred to the SICU for care. A Levophed drip was used. ID
was consulted
Intraop, he spiked a temperature to 104 and became hypotensive
most likely from ATG reaction vs infection. He received
Vancomycin and Levaquin perioperatively and was pancultured for
this fever. Urine culture from [**9-2**] grew >100,000 colonies of
E.coli pan-sensitive. ID was consulted and felt that fever most
likely due to ATG than infectious etiology and recommended broad
spectrum antibiotics (vanco/aztreonam and flagyl).
A renal transplant US was done which was significantly limited
due to patient body habitus and intubated status preventing
adequate breathhold. Doppler waveforms within the upper, inter,
and lower pole demonstrated brisk systolic upstroke and
diastolic flow with slightly elevated RIs of greater than 0.8.
Additionally, waveforms in the renal hila, which were difficult
to obtain, demonstrated diminished diastolic flow. Numerous
attempts to identify flow within the transplant main renal vein
were unsuccessful. CVVHD was begun for hyperkalemia (7.7)and
delayed graft function on pod 1.
He was extubated and transferred out of the SICU to the med-[**Doctor First Name **]
unit.
Nephrology followed him and tailored HD accordingly. The
tunnelled HD line that was present preoperatively was removed
and replaced with a L IJ temporary HD line. This temporary line
was very positional and uncomfortable during HD and was
subsequently replaced on [**9-14**]. Again this catheter was exchanged,
but did not work during HD on [**9-16**] requiring removal. A L
subclavian tunnelled HD line was successfully placed on [**9-16**]. He
received HD on [**9-16**].
A renal transplant biopsy was performed on [**9-9**]. The pathology
report on the biopsy was negative for cellular and humoral
rejection. The differential diagnosis included obstruction, drug
nephrotoxicity, and especially "acute tubular necrosis." The
small focus of interstitial neutrophils raised the possibility
of an infectious process. There was considerable chronic (donor)
vascular disease.
For immunosuppression, he remained on cellcept 1gram [**Hospital1 **],
steroid taper to prednisone 25mg qd and prograf [**Hospital1 **]. Prograf
required up titration to as high as 22mg [**Hospital1 **] to achieve trough
levels of 9.4. This unusually high dosage was due to interaction
with his HAART medication. The decision was made to give prograf
15mg q 8 hours as it was difficult to get obtain appropriate
troughs on [**Hospital1 **] dosing and to avoid high peaks and prevent
vasoconstriction. Prograf was dosed at 6am, 2pm and 10pm.
The abdominal incision continued to ooze large amounts of old
bloody fluid from a hematoma. The incision was opened on [**9-13**] and
a vac was placed. Vac outputs averaged 1 liter per day of
serosanguinous.
Urine output continued to be low averaging 50-100cc/24 hours.
Creatinine ranged between 8.5 and 10.5 decreasing due to
dialysis.
Hematocrit trended down to 24 (from preop 35.6) and remained
stable. Epogen was administered at HD. Iron studies revealed a
ferritin of 592, tsf 183 and cal TIBC 238.
Physical therapy evaluated and recommended rehab. He will be
transferred to [**Hospital **] Rehab Hospital with continuation of HD
and lab monitoring q Monday and Thursday. Labs results should be
fax'd immediately when available to the [**Hospital 1326**] Clinic attn:
[**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN coordinator. Immunosuppression should only
be adjusted by the Transplant Center.
Medications on Admission:
abacavir 300mg [**Hospital1 **], lamivudine 50mg po qd, efavirenz 600mg qd,
albuterol mdi prn, atorvastin 20mg qd, lomotil 1 tab prn quid,
cymbalta ? dose, [**Doctor First Name 130**] prn, advair ? dose, atrovent 1 puff
[**Hospital1 **],lopressor 100mg [**Hospital1 **], asa 81 qd, requip 2mg qd,
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection four times a day.
Disp:*1 vial* Refills:*2*
2. syringes Sig: One (1) syringe four times a day: supply 28
gauge low dose insulin syringes U 100.
Disp:*1 box* Refills:*2*
3. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous four
times a day.
Disp:*1 kit* Refills:*2*
4. Lancets,Ultra Thin Misc Sig: One (1) lancets
Miscellaneous four times a day: follow sliding scale.
Disp:*1 box* Refills:*2*
5. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*2*
6. Alcohol Wipes Pads, Medicated Sig: One (1) Topical four
times a day.
Disp:*1 box* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Efavirenz 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
15. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
16. Lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
19. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
21. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
23. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
24. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
25. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
26. Oxycodone 5 mg Tablet Sig: 5-10 Tablets PO Q4H (every 4
hours) as needed for pain.
27. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
28. Tacrolimus 5 mg Capsule Sig: Three (3) Capsule PO Q 8H
(Every 8 Hours): administer at 6am, 2pm and 10pm.
29. Outpatient Lab Work
Labs every Monday and Thursday for cbc, chem 10, and trough
prograf level
Fax labs to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESRD
HIV
s/p Cadaveric Renal Transplant
Delayed graft function
UTI, E.coli
Incision wound
Anemia
Discharge Condition:
good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down medications, increased abdominal pain, increased
drainage from abdominal wound vac, increased urine output
Monitor the incision for increased drainage, redness or bleeding
Continue VAC dressing changes every 72 hours
Continue Hemodialysis every Tuesday-Thursday & Saturday
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-9-21**] 2:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2189-9-22**] 10:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-9-22**] 11:20
Provider: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1105**] [**Telephone/Fax (1) 14167**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 819**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
Completed by:[**2189-9-17**]
ICD9 Codes: 412, 5856, 5990, 2767, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4687
} | Medical Text: Admission Date: [**2125-7-13**] Discharge Date: [**2125-7-24**]
Date of Birth: [**2073-8-19**] Sex: F
Service: [**Last Name (un) **]
The patient is a 51-year-old female with past medical history
significant for herpes, hepatitis C, hypertension, diabetes
status post mechanical valve placed in [**2123**], on Coumadin, who
presented with 1-day history of consistent crampy abdominal
pain, periumbilical in nature. It was persistent with loose
watery diarrhea. Pain was consistently getting worse,
radiating to the back. The patient's pain continued to get
worse prior to admission. She then developed nausea and
vomiting, is diaphoretic, and sought attention in the
emergency department.
PAST MEDICAL HISTORY: As above. Hypertension.
Heart disease.
Depression.
Migraines.
Hepatitis C.
Herpes.
PAST SURGICAL HISTORY: Total abdominal hysterectomy.
AVR.
MVR.
St. Jude's valve.
MEDICATIONS:
1. Coumadin.
2. Fioricet.
3. Lexapro.
4. Lisinopril.
5. Toprol.
PHYSICAL EXAMINATION: On examination, she was afebrile.
Vital signs were stable; however, she was in some abdominal
distress. She was admitted with a diagnosis of pancreatitis,
had a significant [**Last Name (un) 5063**] criteria. Amylase was [**2056**] on
admission, LDH was 423. The patient was admitted to the ICU
and was aggressively fluid resuscitated. The patient was
started on a heparin drip in order to maintain the
anticoagulation for her St. Jude's valve. However in the
ICU, after the first night, her INR jumped to 9.1 because of
her acute illness. The patient had increasing difficulties
in the pulmonary status and was intubated prophylactically in
order to be able to continue to ventilate her and was
continued to aggressively be fluid resuscitated. She had a
gas of 7.23, 47, 51, and base deficit of 8. Her abdomen
remained diffusely tender.
Her white count remained slightly elevated around 14 and her
ABG, eventually after fluid resuscitation began to normalize.
HOSPITAL COURSE: The pancreatitis care was continued. The
patient was placed on a heparin drip and Coumadin was
discontinued. NG tube was placed, CVL was placed. Patients
with an INR, though continued after FFP was given. The
patient continued to have some clotting difficulties with the
recent placement of the CVL on the right IJ. On [**2125-7-15**],
the heparin drip was being held because the patient's
anticoagulation continued to be a difficult issue. This was
then rectified after fluid status began to respond. The
patient was continued on n.p.o. and was intubated. In order
to better establish fluid status, a Swan was placed.
However, the patient in a period of agitation self-
discontinued the Swan. She was agitated. On [**2125-7-18**], the
patient had significantly improved. She extubated in the
unit on [**2125-7-17**], significantly improved, and her abdominal
examination continued to improve. It was decided the patient
met criteria for gentle sips. Sips were provided. The
patient tolerated the sips and she continued to do well. On
hospital day 6, it was decided the patient should be
transferred out of the unit. The patient was transferred out
of the unit and was transferred to the floor. She continued
to improve on the floor. Her diet was advanced. Her
activity level was increased. Her access was removed and
peripheral access was used and the patient continued to
improve. She was on TPN; however, this was weaned off, as
she had been on TPN in the unit. This was then weaned off
and the patient was continued to be on a heparin drip with
goal between 60 and 80. However, the Coumadin was started
and when the INR reached therapeutic 2.5, it was decided that
patient had met criteria for discharge. Therefore, the
patient was discharged in stable condition with an INR of 2.5
to protect the St. Jude's valve. She had recovered fully
from her bout of pancreatitis. Was tolerating a regular
diet, and had a normal activity level, and was discharged in
stable condition.
PRIMARY DIAGNOSIS: Pancreatitis.
SECONDARY DIAGNOSIS: Mechanical valve anticoagulation.
TERTIARY DIAGNOSIS: Respiratory insufficiency, needing for
intubation.
OTHER SECONDARY DIAGNOSES: Diabetes mellitus.
Hypertension.
Hepatitis C.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2125-7-23**] 11:53:18
T: [**2125-7-23**] 21:21:44
Job#: [**Job Number 105945**]
ICD9 Codes: 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4688
} | Medical Text: Admission Date: [**2144-7-3**] Discharge Date: [**2144-7-15**]
Service: Medicine
ADMISSION DIAGNOSIS:
Pancreatic cancer.
DISCHARGE DIAGNOSIS:
Pancreatic cancer, cholangitis.
DISCHARGE STATUS: To rehab.
ADDENDUM TO HOSPITAL COURSE: 1. Cardiovascular: The patient
was continued to be monitored on telemetry and rate control for
irregular heart rate. The patient was placed on Diltiazem and
Digoxin in house. The patient's rate responded to additional
medication. Of note two nights prior to discharge the patient
had a 28 beat run of his ventricular tachycardia versus a
rapid afib rhythm on telemetry. Electrolytes were checked and
were normal.
2. Infectious disease: The patient finished her ID course
of Ciprofloxacin in house for cholangitis.
3. Access: The patient had a PICC line in house, which was
discontinued.
DISPOSITION: The patient is discharged to rehab.
DISCHARGE MEDICATIONS:
1. Guaifenesin 5 ml po q 4 prn.
2. Aspirin 325 mg suppository.
3. Miconazole one application prn.
4. B-12 as needed.
5. Diltiazem 120 mg po q.i.d.
6. Lansoprazole 30 mg po q.d.
7. Insulin as directed by nursing and NPH 4 units q.a.m. 2
units q p.m. with sliding scale coverage.
8. Digoxin 125 mcg po q.d.
9. Lovenox 40 units sq 24 hours.
10. Diltiazem HCL 60 mg one tab q.i.d.
DISCHARGE CONDITION: Fair. Discharged to rehab. The
patient should have physical therapy and occupational
therapy. The patient will have need for wheelchair.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2144-7-15**] 08:26
T: [**2144-7-15**] 08:54
JOB#: [**Job Number **]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4689
} | Medical Text: Admission Date: [**2197-2-19**] Discharge Date: [**2197-3-15**]
Date of Birth: [**2125-8-5**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Vicodin / Zosyn
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
S/P Fall with multiple fx
Major Surgical or Invasive Procedure:
R humerus closed reduction
R humerus ORIF
History of Present Illness:
71 M c CAD/CHF, AICD c BiV pacer, Afib on coumadin, DM on
insulin who presents after a mechanical fall onto R side.
History from wife who is at patient's bedside; pt. somnolent.
Pt. squatting to feed cat and on rising had mechanical fall with
twisting motion onto R side. Unwitnessed. Denies LOC. Wife found
patient down complaining of pain at R shoulder and R hip. Also
denies any preceding CP, SOB, lightheadedness, dizziness,
palpitations, bowel/bladder incontinence.
.
Presented to [**Hospital1 1474**] ED and found to have R transverse humeral
neck fracture and R acetabular fracture and pubic ramus
fracture. Transfered to [**Hospital1 18**] ED.
.
In ED, VSS and AF. Seen by ortho; closed reduction performed on
R humeral fracture and felt to require ORIF for acetabular
fracture. Recommended hold on all anti-coagulation. Pain well
controlled with IV Dilaudid 1 mg * 2 though pt. somewhat
somnolent. Noted to have Cr 2.5 in ED; baseline is unknown.
.
Per conversation today with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], (OSH records
pending), pt is CRF with baseline creat 2.5-2.7. Per
conversation, PCP has old notes that indicate baseline O2 sats
in high 80s - low 90s. Pt had angiograms of legs recently by
vascular which worsened his renal function (now returned to
baseline CRF).
.
ROS: No recent orthopnea, PND, urinary problems. Wife does
report two recent hospitalizations; first at [**Hospital3 417**] for
lower extremity pain thought [**12-30**] PVD. Pt. underwent angiography
c intervention as per wife with some relief of symptoms. Second
at [**Hospital 1474**] hospital 1 week prior for lower extremity pain and
SOB; found to have O2 sat 84% RA; thought [**12-30**] URI and pt.
treated with a prednisone taper; however, pt. lacks a formal
diagnosis of COPD. Wife mentions that pt's potassium level was
high on that admission but unclear etiology of this. Normally
the patient is able to walk about 50 feet across his ranch
house, prepares his own meals, dresses himself, and occasionally
drives.
Past Medical History:
1. Congestive Heart Failure - EF 15% by previous notes
2. CAD s/p CABG [**2184**] and AICD c [**Hospital1 **]-V pacer in [**2194**]
3. PVD s/p b/l fem-[**Doctor Last Name **] bypass and TMA; CEA [**2186**]
4. Diabetes on insulin
5. Atrial fibrillation on coumadin
6. Hypothyroidism
7. Hyperlipidemia
8. Obstructive Sleep Apnea
9. Restless Leg Syndrome
Social History:
70 pack year smoking history, drinks a cup of wine each night.
Lives with his wife. Used to work in Community Dev. Program for
[**Location (un) 3320**] MA until 2 yrs prior
Family History:
No hx kidney disease or CAD. Sister c CVA in 70s, Father and
mother lived into mid 90s.
Physical Exam:
VS: 97.3 150/80 77 14 90% RA
GEN: elderly man appears older than stated age, somnolent
HEENT: conjunctivae pink, JVP flat, MMM
RESP: CTA b/l with good air movement throughout
CV: RR, [**1-3**] SM at apex c/w MR. [**First Name (Titles) **] [**Last Name (Titles) **]
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: bilateral TMA. cold to touch. pulses not palpable. +
chronic venous stasis changes. Denuded. Small 2 mm in diameter
ulcer on plantar surface L foot; no purulence/erythema at this
area. 2+ pitting edema over tibia b/l.
SKIN: no rashes/no jaundice
Pertinent Results:
Labs: Cr 2.5, BUN 77, HCT 33.5, INR 4.5. U/A [**5-7**] RBC, lg bld,
prot
.
EKG: Paced rhythm at 80 bpm
.
Imaging:
CXR [**2-20**] - Cardiomegaly. No acute cardiopulmonary process. BiV
pacer leads noted. Multiple surgical clips. No focal
consolidations.
.
Shoulder XR [**2-19**] - Fracture of surgical R humeral neck.
.
Hip XR [**2-19**] - Comminuted fracture of the right acetabulum and
nondisplaced right superior pubic ramus fracture.
.
Knee XR [**2-19**] - No fracture or dislocation
.
TTE [**2-20**] - EF 25-30%. Mild symmetric left ventricular
hypertrophy with regional systolic dysfunction c/w CAD (proximal
LAD lesion). Severe tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension. Mild aortic regurgitation.
Brief Hospital Course:
A/P: 71 y/o M h/o CAD, CHF (EF 25-30%), Severe TR, AICD w/ [**Hospital1 **]-V
pacer, DM2, chronic renal failure, who presents with right hip
and humerus fractures, MICU callout for respiratory failure [**12-30**]
nosocomial pneumonia and volume overload. Now respiratory status
is stable on nasal cannula. s/p R humerus ORIF. R hip not
repaired given surgical risks. Pt was made CMO and passed away
.
# Hypoxia: combination of vol overload and aspiration PNA> for
the vol overload the pt was diuresed with torsemide and lasix.
he aspirated twice leading to desatt and tranfer to ICU. he was
weaned down to O2 by NC and transferred back to the floor. he
was treated with vanco nad aztreonam (zosyn was d/c'ed because
of the concern for AIN). also received nebs.
.
# Systolic/Diastolic Heart Failure: TTE on [**2197-2-20**] showed EF
25-30%, also w/ 4+ TR. SvO2 54%. Clinically volume overload.
continued carvedilol 25mg po bid. planned to start ACE/[**Last Name (un) **] once
ARF resolves. had a BIV pacer and AICD
.
# Fractures: s/p humerus ORIF. Surgical repair of R hip
fracture was on hold given surgical risk. OOB to chair, NWB R
arm and RLE. continued PT
.
# Acute on Chronic Renal Failure: Cr rose from 2.4. Thought
initially to be [**12-30**] diuresis however creatinine continued to
rise despite holding diuresis. FeNa 0.67% indicating a prerenal
process also +urine eos indicated AIN. AIN most likely [**12-30**] zosyn
and changed to aztreonam. Renally dosed meds and antibiotics.
held ACE in setting of ARF
.
# CAD: No evidence for active CAD. S/p CABG in [**2184**]. continued
beta [**Last Name (LF) 7005**], [**First Name3 (LF) **]. held ACE in setting of [**Doctor First Name 48**]. EP interrogated
AICD
.
# Afib: Currently paced; unknown what current underlying rhythm
is. Continue anticoagulation with coumadin. held digoxin in
setting of ARF
.
# PVD: was on pentoxiphylline. vascular saw the pt and did not
feel that there was an acute need for an invasive procedure. pt
was to f/u with his outpt vascular surgeon
.
# DM/hypoglycemia: continued sliding scale insulin
.
#. Hyperlipidemia - Continued home regimen of lipitor
.
# Hypothyroid - Continued home regimen of levothyroxine
.
# OSA: home regimen of CPAP 5 cm H20 + 2Lpm O2
.
# FEN: diabetic/heart healthy diet. replete lytes
.
# Communication: With pt and wife [**Telephone/Fax (1) 63336**]; PCP: [**Name Initial (NameIs) 3314**]
([**Location (un) 1475**]) [**Telephone/Fax (1) 3183**] (Secretary [**Doctor First Name **] [**Telephone/Fax (1) 63337**]),
Outpt Cards: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Cards: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
.
# Access: PIV, R IJ CVL
.
# PPx: anticoagulated, pneumoboots, Protonix
.
# Code: DNR/I
Medications on Admission:
1. Trental 400 mg tid
2. Coreg 25 mg [**Hospital1 **]
3. Digoxin 125 mcg daily
4. Lasix 60 mg [**Hospital1 **]
5. Coumadin 6 mg daily
7. Synthroid 112 mcg daily
8. Lipitor 40 mg daily
9. Xalatan gtt daily
10. Klonopin 0.5 mg qhs
11. Phoslo 667 mg tid
12. Folate 1 mg daily
13. Colace/Senna
14. Fluticasone 1 spray daily both nostrils
15. Serevent 1 puff [**Hospital1 **]
16. Albuterol 2 puffs qid PRN
17. Insulin - Novolog 70/30 26 u breakfast, 14 u dinner
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
1. Right humerus fracture s/p repair
2. Right acetabular fracture s/p ORIF
3. Right pubic ramus fracture
4. CAD Native Vessel s/p CABG [**2184**]
5. Severe LVSD
6. AICD with biventricular pacer
7. Atrial Fibrillation
8. Ventricular Tachycardia
9. Aspiration Pneumonia
10. Acute Renal Failure
11. Anemia of Chronic Renal Disease
12. Osteoporosis.
.
Secondary Diagnosis:
1. Diabetes mellitus, insulin-dependent
2. Chronic kidney disease stage III/IV
3. PVD s/p bilateral fem-[**Doctor Last Name **] BPG and TMA
4. Hypothyroidism
5. Hyperlipidemia
6. Obstructive Sleep Apnea
7. Restless leg syndrome
8. Chronic Obstructive Pulmonary Disease
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2197-3-24**]
ICD9 Codes: 4280, 5849, 5856, 5070, 4254, 4271, 2875, 2851, 2761, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4690
} | Medical Text: Admission Date: [**2190-10-12**] Discharge Date: [**2190-10-23**]
Date of Birth: [**2109-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2190-10-15**] Coronary artery bypass grafts x 3 - left internal
mammary to left anterior descending arety, with saphenous vein
grafts to ramus and posterior descending artery
[**2190-10-18**] Placement of Right Sided Chest Tube
History of Present Illness:
Mr. [**Known lastname 81870**] is an 81 year old male with recent complaints of
chest pain and shortness of breath. Given multiple cardiac risk
factors, he underwent cardiac catheterization which revealed
severe three vessel coronary artery disease and decrease LV
function with an ejection fraction of 35%. He was transferred to
the [**Hospital1 18**] for cardiac surgical evaluation and treatment.
Past Medical History:
Coronary Artery Disease, Chronic Systolic Heart Failure
Hypertension
Dyslipidemia
Cerebrovascular Disease - s/p Right Carotid Endarterectomy [**2185**]
Low Back Pain, Spinal Stenosis, Herniated Discs
Left Foot Drop
History of Right Ankle Fracture
s/p Resection of Benign Colonic Tumor
s/p Repair of Abdominal Stab Wound
s/p Carpal Tunnel Surgery
Social History:
Remote cigar smoker. Denies ETOH. Retired.
Family History:
One brother underwent CABG. Another brother died after
undergoing heart surgery.
Physical Exam:
Admit PE
Vitals: BP 138/78, HR 65, RR 18, SAT 98% 2L
General: Elderly male in no acute distress
HEENT: Oropharynx benign
Neck: Supple, no JVD
Heart: Regular rate and rhythm, normal s1s2, soft systolic
ejection murmur
Lungs: clear bilaterally
Abdomen: benign
Ext: warm, no edema
Neuro: alert and oriented, cn 2-12 grossly intact, no focal
deficits
Pulses: 1+ bilaterally, no carotid or femoral bruits noted
Pertinent Results:
[**2190-10-12**] 09:21PM BLOOD WBC-4.9 RBC-3.87* Hgb-12.9* Hct-35.1*
MCV-91 MCH-33.4* MCHC-36.9* RDW-13.2 Plt Ct-243
[**2190-10-12**] 09:21PM BLOOD PT-13.7* PTT-27.2 INR(PT)-1.2*
[**2190-10-12**] 09:21PM BLOOD Glucose-178* UreaN-14 Creat-1.3* Na-132*
K-3.9 Cl-100 HCO3-26 AnGap-10
[**2190-10-14**] 05:35AM BLOOD CK-MB-10 cTropnT-0.32*
[**2190-10-12**] 09:21PM BLOOD Albumin-3.8 Mg-2.1
[**2190-10-14**] 05:35AM BLOOD %HbA1c-5.5
[**2190-10-13**] ECHO:
The left atrium is moderately 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 regional left ventricular systolic
dysfunction with infero-lateral akinesis. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2190-10-13**] Carotid Ultrasound:
No stenosis of the right ICA. Less than 40% left ICA stenosis.
[**2190-10-15**] Intraop TEE:
PRE-BYPASS
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is severe global left ventricular hypokinesis. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
POST-BYPASS
1. Patient is being AV paced and receiving an infusion of
epinephrine.
2. LV systolic function is 35%.
3. Mild mitral regurgitation persists.
4. Aortic insufficiency is mild.
5. Aorta intact post decannulation.
[**2190-10-22**] 05:25AM BLOOD WBC-5.6 RBC-3.30* Hgb-10.4* Hct-30.1*
MCV-91 MCH-31.6 MCHC-34.7 RDW-13.3 Plt Ct-250
[**2190-10-22**] 05:25AM BLOOD Glucose-105 UreaN-24* Creat-1.1 Na-135
K-4.4 Cl-98 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 81870**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Workup included
echocardiogram and carotid ultrasound - please see result
section for results. He remained pain free on medical therapy.
His preoperative course was otherwise uneventful and he was
cleared for surgery.
On [**10-15**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated. On postoperative day
two, following removal of pleural chest tubes, chest x-ray was
notable for a 15% right pneumothorax. He eventually
decompensated which required re-intubation with placement of a
chest tube. Over the next 24 hours, his oxygenation improved and
he was re-extubated without incident.
He was transferres to the step down floor on POD 4. The chest
tube was removed on POD 7. Repeat CXR on POD 8 showed resolution
of small right apical pneumothorax. Patient passed physical
therapy and was cleared to be discharged to his sisters house
where he will stay for 2 weeks before returning to [**State 1727**].
Medications on Admission:
ASA 325mg/D
Toprol XL 25mg/D
Zocor 20mg/D
NTG 0.4 mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily) for 5 days.
Disp:*5 Packet(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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] home health
Discharge Diagnosis:
coronary artery disease
s/p right carotid endarterectomy
hypertension
hyperlipidemia
chronic low back pain
s/p colon resection
s/p right carpal tunnel release
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimmign
no lotions, creams or powders to incisions
report any fever greaterthan 100.5
report any redness of, or drainage from incisions
report any weight gain of 2 pounds a day or 5 pounds a week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital 409**] clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] in [**12-2**] weeks
please call for appointments
Completed by:[**2190-10-23**]
ICD9 Codes: 4019, 4241, 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4691
} | Medical Text: Admission Date: [**2158-6-13**] Discharge Date: [**2158-6-17**]
Date of Birth: [**2089-9-16**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 68 year old male with
a history of diabetes mellitus and hyperlipidemia, who
complains of five to six days of chest pain and shortness of
breath that was intermittent in nature, significantly worse
in the afternoons. On the afternoon of admission, the
patient was unremitting and was associated with
lightheadedness, diaphoresis and nausea. The patient's son
convinced him to go to the Emergency Room. At [**Hospital1 346**], the patient was given aspirin,
heparin, Nitroglycerin, and taken to catheterization.
The catheterization results revealed a 50% mid- left anterior
descending lesion with an additional long 80% mid- left
anterior descending lesion with an additional 70% distal left
anterior descending lesion and a 60% diagonal lesion. The
left circumflex had no significant disease. The right
coronary artery had 100% proximal stenosis after the right
ventricular marginal branch.
Three proximal right coronary artery stents were placed,
however, the procedure was complicated by the temporary loss
of the right ventricular marginal branch during the
procedure, however, this artery became patent later in the
procedure. The procedure was also complicated by a probable
contained coronary perforation distally from a guide wire
with contrast appearing to drain into the venous structure
and multiple echocardiograms showing no effusion.
Additionally, the procedure was complicated by two episodes
of ventricular fibrillation which each responded to a single
shock.
Repeat angiogram after the procedure showed all vessels
stented were patent. The patient was admitted to the Cardiac
Care Unit and the chest pain had resolved at the time of
admission to the Unit.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hyperlipidemia.
MEDICATIONS AT HOME:
1. Glucophage.
2. Glyburide.
3. Zestril.
4. Pravachol.
5. Claritin.
ALLERGIES: No allergies.
PHYSICAL EXAMINATION: On admission, his vital signs were
98.6 F. Temperature; pulse was 78; blood pressure 92/55;
respiratory rate 18; the patient was saturating 99% on room
air. Generally, he was alert and oriented times three in no
acute distress. He was an elderly male. HEENT: His Pupils
equally round and reactive to light and accommodation.
Mucous membranes were dry. The oropharynx was clear.
Extraocular movements are intact. His neck examination
showed no jugular venous pressure while lying flat, no
carotid bruits, no thyromegaly, no lymphadenopathy.
Cardiovascular examination had a regular rate, normal S1,
normal S2. No murmurs, rubs and no gallops. Abdomen was
soft, nontender, nondistended, with active bowel sounds. His
extremities: Doppler positive posterior tibial and dorsalis
pedis pulses bilaterally, however the pulses were not
palpable. The patient had no edema. The patient had two
plus capillary refill bilaterally.
LABORATORY: Upon admission, he had a white blood cell count
of 8.2, hemoglobin of 11.1, hematocrit of 31.5, platelets
were 195 and an INR of 1.0, PTT of 26. He had a sodium of
137, potassium of 4.3, chloride of 102, bicarbonate 21, BUN
27, creatinine 1.2, glucose of 200.
CK on presentation was 1577, CK MB was 107, CK index was 6.8.
EKG results at admission were premature atrial complexes,
evidence of inferior infarction, probably acute, considered
posterior long involvement; no previous report for comparison
is showed. ST elevations in inferior and posterior leads as
well as AVR and before R.
HOSPITAL COURSE:
1. Cardiovascular: 1) Coronary artery disease; the patient
was started on aspirin and Plavix, however, the usual dose of
Integrilin was held secondary to perforated right coronary
artery due to the risk of tamponade. The patient was also
started on Lipitor 10 mg after liver tests showed relatively
normal transaminase levels. 2) Pump; the patient was started
on a low dose of Metoprolol and Zestril. Additionally, the
day prior to discharge the patient was taken back to
catheterization laboratory and his left anterior descending
lesions were stented with no complications. The patient's PA
diastolic pressures and serial echocardiograms were all
consistent with normal right ventricular function and there
was no evidence of tamponade. Throughout his hospitalization
the patient was also free of symptoms such as edema,
hepatomegaly and jugular venous pressure that would have
indicated right sided failure. 3) Rhythm; the patient's
ventricular fibrillation in the catheterization laboratory
was likely a reperfusion arrhythmia which responded well to
defibrillation. The patient was started on a Lidocaine drip
that was continued for 24 hours and discontinued. The
patient had no other dysrhythmias throughout his
hospitalization despite monitoring on Telemetry.
2. Pulmonary: The patient was saturating 99% on room air on
admission and continued to saturate in the high 90s on room
air. He had no signs of left ventricular failure or right
ventricular failure throughout his hospitalization.
3. Renal: The patient's urine output was initially low and
was thought to be a result of his low normal blood pressure
which was 95 to 100 over 50 to 60. However, his urine output
picked up throughout his hospitalization and BUN and
creatinine remained stable throughout his hospitalization.
4. Fluids, Electrolytes and Nutrition: The patient was
started on a cardiac diet as well as diabetic diet. The
patient was encouraged to continue on a diabetic diet after
discharge.
5. Endocrine: The patient was a known non-insulin dependent
diabetic and was not restarted on his oral hypoglycemics,
however, he was covered with a sliding scale insulin which
was minimally used throughout his hospitalization. The
patient was to be restarted on his outpatient hypoglycemic
regimen when he was discharged. This can be attenuated by
his primary care physician and was not attenuated by us here
in the hospital.
6. Prophylaxis: The patient received Protonix for peptic
ulcer disease prophylaxis and Docusate for constipation.
Additionally, the patient received Ambien on the last night
of his hospitalization for sleep.
CONDITION AT DISCHARGE: The patient was discharged home in
good condition.
DISCHARGE MEDICATIONS:
1. Glucophage and Glyburide as previously dosed.
2. Zestril 5 mg p.o. q. day.
3. Lopressor 50 mg p.o. twice a day.
4. Lipitor 10 mg p.o. q. day.
5. Plavix 75 mg p.o. q. day.
6. Aspirin 325 mg p.o. q. day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2158-6-17**] 07:58
T: [**2158-6-19**] 10:47
JOB#: [**Job Number 43457**]
ICD9 Codes: 9971, 4271, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4692
} | Medical Text: Admission Date: [**2139-4-27**] Discharge Date: [**2139-5-6**]
Date of Birth: [**2085-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Paralysis, epidural hematoma
Major Surgical or Invasive Procedure:
Placement of a peripherally inserted central catheter (PICC
line)
Endotracheal Intubation
Blood Transfusion
Arterial Line
History of Present Illness:
Mr. [**Known lastname **] is a 53 year old man with a history of anxiety,
polysubstance abuse (hepatitis B and C), peripheral vascular
disease, HTN, COPD who presented with 3-4 days of increasing
lower extremity weakness. Unfortunately, he is currently
intubated/sedated and cannot provide a history. Per review of
nursing home records and emergency department records, he noted
decreased sensation in his lower extremities, starting on the
left. This was accompanied by increasing weakness. These
symptoms occured in the setting of his girlfriend moving a
pillow for him 3-4 days ago. Apparently denied trauma. He was
initially seen at an OSH where he had an L-spine MRI that showed
an acute to subacute fx at L1-L2.
In the ED, initial vs were: 97.4 HR 111 100/63 RR 20 94% on
6 L. He was intubated for an MRI. In the MRI, he became
hypotensive with SBP to 80-90s. He was started on levophed and
was given vancomycin and zosyn. For sedation he was given
versed 5 mg IV and vecuronium 8 mg for MRI and was started on
versed/fent drips. MRI revealed a compression fx at T6-7 with
an epidural collection likely hematoma. Per radiology read,
there is suggestion of mass effect on cord. Per neurosurgery
review of films, neurosurgery feels that there is in fact no
mass effect. Neurosurgery attending was contact[**Name (NI) **] by both the
neurology and [**Name (NI) **]. It was felt that Mr. [**Known lastname **] would not
benefit from an immediate surgical intervention and would best
be served on the medical service. Of note a RIJ was placed in
the ED prior to transfer to the floor.
.
On the floor, he is intubated and sedated. He grimaces to pain
but does not respond to simple commands.
Past Medical History:
- Anxiety,
- Hep B and C
- SAH
- PVD
- HTN
- COPD on [**4-23**] L O2 at home
- Recent Pneumonia
Social History:
Mr. [**Known lastname **] has been at [**Hospital 5503**] Rehab Hospital, recently
admitted OSH w/ discharge diagnosis of COPD exacerbation on IV
vancomycin and solumedrol.
-H/O IVDU, states he has not used in years.
Family History:
Unable to obtain on admission
Physical Exam:
General: Intubated, sedated
HEENT: Sclera anicteric
Neck: supple, no LAD
Lungs: Anterior breath sounds clear, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: Cool, 1+ pulses, no clubbing, cyanosis or edema
Skin: Multiple ecchymoses, Stage 2-3 sacral decubitus ulcer
Neuro: Strength/sensation unable to assess, patellar refelx
0/ankle jerk 0, Babinski equivocal
Pertinent Results:
Imaging
.
[**2139-4-27**] MRI Spine
IMPRESSION:
1. Mild-to-moderate compression fractures of T5 through T7 with
a
heterogeneously enhancing epidural collection, concerning for
ostemyelitis
with evolving epidural abscess. However, the lack of extensive
enhancement
including the disc space is unusual for pyogenic infection and
there may be a combination of chronic neurogenic
spondyloarthropathy with hematoma/phlegmon and superimposed
infection. TB could have this appearance and should be
correlated with clinical and laboratory findings. There is
resultant severe encroachment on the spinal canal anteriorly
with cord deformity and abnormal cord signal.
2. Findings concerning for a developing secondary infection at
C5-6 without cord compression. While the endplate and disc edema
could be post-traumatic, the extent of epidural enhancement
would be very unusal in the setting of trauma.
3. Mild compression fractures of L1 and L2 without cord or cauda
equina
compression.
4. Additional degenerative changes as detailed.
5. Pulmonary findings concerning for pleural and/or parenchymal
disease for which chest CT has been recommended and please see
that report for further details.
.
[**2139-4-28**] CT Chest
IMPRESSION:
1. Severe bilateral, occlusive bronchial mucoid impaction.
2. No appreciable pleural effusion, loculated or otherwise.
Right basal
atelectasis is moderate.
3. Diffuse centrilobular emphysema.
4. Possible aspiration effect, right middle lobe and right lower
lobes
5. Diffuse debris is noted within the tracheobronchial tree.
Dense secretions are noted in the right lower lobe and left
lower lobe bronchi.
6. Vertebral body wedge compressions T5, T7 , T8, L1 with
suggestion of lytic lesions in at least in T8, possible
paraspinal hematoma, tumor, and/or marrow, better described on
same day CT and MR.5.
7. 7 x 9 mm nodule, left upper lobe, could be malignant.
.
[**2139-4-28**] Lower Extremity Doppler
IMPRESSION: No evidence of DVT in the lower extremities
bilaterally.
.
[**2139-4-28**] ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal/small. Left ventricular systolic function appears grossly
preserved. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
free wall motion appears borderline preserved in suboptimal
views. The ascending aorta is mildly dilated. The aortic valve
is not well seen. The mitral valve leaflets are structurally
normal. The estimated pulmonary artery systolic pressure is
normal. There is a very small pericardial effusion. No valvular
regurgitation is identified in suboptimal views.
.
[**2139-4-28**] CT Spine
IMPRESSION:
1. Multiple thoracolumbar compression fractures as described
above.
2. Mild multilevel degenerative disease with grade 1
retrolisthesis of L5 on S1, posterior disc bulge with mild
central canal narrowing.
3. At T7 level, there is paravertebral soft tissue thickening
which appears to be subpleural in location
.
[**2139-4-30**] MRI SPine
IMPRESSION:
1. Continued abnormal signal in the cervical spine at C6-7
level, but
significant decrease in epidural collection at this level.
2. Multiple T5-7 compression fractures are again seen, with
minimal decrease in epidural collection at this level, but
continued abnormal cord signal thought due to mass effect.
For more detailed description of degenerative changes at other
levels, please refer to previous extensive report from three
days prior
.
[**2139-5-1**] CXR
IMPRESSION: No significant change of bibasilar atelectasis.
Stable positions.
.
[**2139-5-6**] CXR
Report pending at discharge.
of ET tube and right central venous catheter.
.
Microbiology
[**2139-5-3**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-5-3**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-5-2**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-30**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-pending;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-negative
[**2139-4-29**] CATHETER TIP-IV WOUND CULTURE-negative
[**2139-4-28**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-negative;
RESPIRATORY CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-negative;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-negative
[**2139-4-28**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
[**2139-4-28**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-27**] URINE URINE CULTURE-FINAL {YEAST}
[**2139-4-27**] BLOOD CULTURE Blood Culture- pending at discharge
.
Laboratory Results
[**2139-4-27**] 08:00PM BLOOD WBC-15.9* RBC-3.04* Hgb-9.3* Hct-28.1*
MCV-92 MCH-30.6 MCHC-33.2 RDW-18.6* Plt Ct-318
[**2139-4-29**] 03:24AM BLOOD WBC-14.5* RBC-2.62* Hgb-7.9* Hct-23.8*
MCV-91 MCH-30.1 MCHC-33.1 RDW-18.7* Plt Ct-358
[**2139-5-1**] 06:17AM BLOOD WBC-10.1 RBC-2.63* Hgb-8.1* Hct-24.1*
MCV-91 MCH-30.6 MCHC-33.5 RDW-18.8* Plt Ct-371
[**2139-5-3**] 05:45AM BLOOD WBC-8.9 RBC-2.44* Hgb-7.5* Hct-22.1*
MCV-91 MCH-31.0 MCHC-34.1 RDW-18.8* Plt Ct-370
[**2139-5-4**] 09:40AM BLOOD WBC-11.0 RBC-3.30*# Hgb-10.0*# Hct-29.4*#
MCV-89 MCH-30.4 MCHC-34.1 RDW-18.3* Plt Ct-323
[**2139-5-5**] 05:53AM BLOOD WBC-8.6 RBC-2.90* Hgb-9.2* Hct-26.0*
MCV-90 MCH-31.6 MCHC-35.2* RDW-18.4* Plt Ct-285
[**2139-5-6**] 05:37AM BLOOD WBC-8.7 RBC-3.15* Hgb-9.5* Hct-28.5*
MCV-91 MCH-30.2 MCHC-33.4 RDW-18.0* Plt Ct-344
[**2139-4-27**] 08:00PM BLOOD Glucose-74 UreaN-41* Creat-0.9 Na-133
K-4.8 Cl-91* HCO3-35* AnGap-12
[**2139-4-29**] 03:24AM BLOOD Glucose-91 UreaN-29* Creat-0.6 Na-136
K-4.2 Cl-99 HCO3-30 AnGap-11
[**2139-4-30**] 06:16PM BLOOD Glucose-92 UreaN-28* Creat-0.6 Na-139
K-3.9 Cl-98 HCO3-33* AnGap-12
[**2139-5-2**] 06:29AM BLOOD Glucose-84 UreaN-30* Creat-0.6 Na-136
K-3.9 Cl-96 HCO3-34* AnGap-10
[**2139-5-3**] 05:45AM BLOOD Glucose-80 UreaN-28* Creat-0.4* Na-136
K-3.8 Cl-98 HCO3-33* AnGap-9
[**2139-5-6**] 05:37AM BLOOD Glucose-71 UreaN-25* Creat-0.5 Na-137
K-3.8 Cl-99 HCO3-33* AnGap-9
[**2139-4-28**] 03:40AM BLOOD CK(CPK)-112
[**2139-4-28**] 09:27AM BLOOD CK(CPK)-78
[**2139-4-28**] 04:44PM BLOOD CK(CPK)-57
[**2139-4-29**] 03:24AM BLOOD CK(CPK)-42*
[**2139-4-27**] 08:00PM BLOOD Lipase-27
[**2139-4-28**] 03:40AM BLOOD CK-MB-4 cTropnT-0.12*
[**2139-4-28**] 09:27AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2139-4-28**] 04:44PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2139-4-29**] 03:24AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2139-4-28**] 03:40AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
[**2139-5-6**] 05:37AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
[**2139-5-3**] 05:45AM BLOOD calTIBC-209* Ferritn-1101* TRF-161*
[**2139-4-28**] 03:40AM BLOOD Cortsol-7.7
[**2139-4-29**] 03:24AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2139-4-27**] 08:00PM BLOOD CRP-69.1*
[**2139-5-3**] 05:45AM BLOOD PEP-NO SPECIFI
[**2139-5-2**] 06:29AM BLOOD HIV Ab-NEGATIVE
[**2139-4-29**] 08:13AM BLOOD Vanco-23.1*
[**2139-4-29**] 09:35PM BLOOD Vanco-15.5
[**2139-5-1**] 06:17AM BLOOD Vanco-20.8*
[**2139-5-2**] 06:29AM BLOOD Vanco-20.2*
[**2139-5-5**] 05:53AM BLOOD Vanco-23.8*
[**2139-4-27**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-4-28**] 01:48AM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
pO2-195* pCO2-58* pH-7.35 calTCO2-33* Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2139-5-2**] 02:08PM BLOOD Type-ART Temp-36.8 pO2-63* pCO2-45
pH-7.49* calTCO2-35* Base XS-9
[**2139-4-27**] 08:30PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2139-4-27**] 08:30PM URINE RBC-[**2-20**]* WBC-[**5-28**]* Bacteri-FEW Yeast-MOD
Epi-0-2
Brief Hospital Course:
Mr. [**Known lastname **] is a 53 year old man with anxiety, hepatitis C,
PVD, HTN, COPD on home O2 who presented with paralysis secondary
to a compression fracture and epidural abscess/hematoma.
.
# Blood pressure: Mr. [**Known lastname **] met SIRS criteria on admission
with leukocytosis and tachycardia. He was initially treated with
levophed and IV boluses for a goal MAP over 60. He was able to
be weaned from pressors and his blood pressures then remained
stable. His blood pressures remained stable throughout the rest
of the hospitalization, but his home medications were not
restarted. He was started on metoprolol for atrial tachycardia.
His home lisinopril and furosemide should be restarted at rehab
as his blood pressure allows.
.
# Epidural Abscess/Bacteremia: Mr. [**Known lastname **] was seen by
neurology and neurosurgery on admission. He was unable to move
or have sensation in his lower extremities. He had no rectal
tone. Given the extent of his deficit, the timing of the injury,
and his comorbidities, neurosurgery did not feel surgery would
be beneficial. He was covered broadly with vancomycin/zosyn
initially for bacteremia and possible epidural abscess. ID was
consulted. Blood cultures from the OSH were positive for MRSA
and his antibiotic coverage was changed to vancomycin based on
sensitivities. After blood cultures were negative here at [**Hospital1 18**]
a PICC was placed. He will need a total of eight weeks of
antibiotic therapy. He will be followed by the [**Hospital **] clinic. He
will need weekly blood draws of vanc trough, chem-7, CRP, ESR,
CBC, and LFT's. He will follow up in [**Hospital **] clinic in two weeks.
Neurosurgery would like him to have a repeat MRI in three months
([**2139-7-19**]). He will need a vanc trough on [**5-7**].
.
# Lung Nodule: Mr. [**Known lastname **] had a lung nodule seen on chest
imaging (9mm). This will need to be followed up with a repeat CT
in 3 months.
.
# COPD/Respiratory failure: Mr. [**Known lastname **] was initially intubated
on arrival in order to have imaging studies performed. He was
able to be quickly extubated on hospital day #2. The following
morning he desaturated to the 70's with increased WOB. He was
reintubated. He remained reintubated overnight and was extubated
the next day. On the floor, he was able to be weaned to 4 L
(home dose 5-6 L). He was initially continued on high dose
steroids for his COPD flare. However, this was decreased to 40
mg of prednisone. He remained on 4 L. His goal oxygen saturation
was 90-92%. He should continue to be slowly tapered on
prednisone while at rehab. He should have a slow taper given his
extended use of solumedrol. He should continue on Bactrim while
on high dose steroids.
.
Compression Fractures: Mr. [**Known lastname **] had compression fractures.
He was started on calcium, vitamin D, and calcitonin. He was
fitted for a TLSO brace. He should always wear the brace when he
is elevated above 30 degrees.
.
Bowel/Bladder Care: Mr. [**Known lastname **] has no rectal tone. He is
unable to sense his bladder and bowels being full. A voiding
trial was attempted, but was unsuccessful. A foley was replaced.
He should have a repeat voiding trial at rehab. He had not moved
his bowels for several days during the hospitalization. He was
given an aggressive bowel regimen. A disimpaction was attempted,
but there was no stool in the rectum. He spontaneously moved his
bowels on the day of discharge. His difficulty with bowel and
bladder symptoms is likely related to his paralysis. His high
dose of narcotics is also worsening the problem.
.
Anemia: Mr. [**Known lastname **] had a slowly decreasing hematocrit. He was
guiac negative. He received two units of pRBC's with an
appropriate increase. His anemia was consistent with anemia of
chronic disease.
.
Pain: Mr. [**Known lastname **] had severe pain related to his compression
fractures. He was started on a PCA with hydromorphone. This was
transitioned to IV and then orals. He was also started on a
lidocaine patch. He was continued on his home methadone dose of
120 mg, but this was spaced out in TID dosing given concerns of
somnolence.
.
Anxiety: Mr. [**Known lastname **] was continued on his home dose of
lorazepam.
.
Lytic Lesions: Mr. [**Known lastname **] was noted to have lytic lesions on
imaging studies. An SPEP was negative. This should be further
evaluated as an outpatient.
.
Wound Care: Mr. [**Known lastname **] was admitted with an unstageable
decubitus ulcer. There were no signs of infection during the
hospitalization. He was followed by wound care. They recommended
daily dressing changes and pressure reduction.
.
Prophylaxis: Neurosurgery felt that it was safe to start DVT
prophylaxis. Based on their recommendation, he was started on
enoxaparin on [**5-3**].
.
Code: Mr. [**Known lastname **] was a full code.
Medications on Admission:
- Lasix 40 daily
- heparin flush
- lisinopril 5 daily
- lorazapam 0.5 TID
- methadone 120 mg
- omeprazole 20
- polyethylene glycol 17 gm daily
- senna daily
- singulair 10 mg daily
- solumedrol 40mg TID
- spiriva 18 mcg
- MVI
- Xopenex neb q6 hours
- Vancomycin (started on [**4-22**] for unclear reason)
- Tylenol
- [**Name (NI) 85137**]
- Bisac-evac
- Guaifenesin
- Ibuprofen
- lorazapam prn
- zolpidem prn
- morphine 2 mg q4 h as needed
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO twice a day.
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation not relieved by colace/senna.
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to back.
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB.
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
21. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for pain.
22. Vancomycin 500 mg Recon Soln Sig: Five Hundred (500) Recon
Soln Intravenous Q 12H (Every 12 Hours): Please continue until
[**6-23**].
23. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis:
Compression Fractures
Epidural Abscess/Hematoma
Chronic Obstructive Pulmonary Disease
Bacteremia
Decubitis Ulcer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with lower extremity weakness and loss
of sensation. You were found to have collections of fluid
pressing against your spinal cord. You met with neurosurgeons
who did not feel an operation would improve your sensation. You
were discharged to a rehab facility to work on improving your
mobility.
We made several changes to your medications:
We STARTED vancomycin (an antibiotic). You will take this until
[**6-23**].
We STOPPED lisinopril and lasix.
We CHANGED your methadone to three times a day at lower doses
(same total dose).
We INCREASED your bowel medications.
WE CHANGED your steroids from solumedrol to prednisone.
We INCREASED your nebulizers to albuterol and ipratropium.
We STARTED calcitonin, calcium, and vitamin D for your bones.
We STARTED oral hydromorphone for breakthrough pain.
We STARTED enoxaparin (Lovenox) to prevent clots from forming.
Followup Instructions:
It is very important that you have a primary care provider. [**Name10 (NameIs) **]
have several medical issues that are important to follow up on.
You will have a physician at your rehab facility. This physician
is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 85138**] [**Name (STitle) 85139**].
You have a pulmonary nodule. You need to have a repeat CT scan
in 3 months to see if this lesion has changed. Please discuss
this with Dr. [**Last Name (STitle) 85139**].
You have an appointment scheduled with Dr. [**Last Name (STitle) 85140**] on [**5-27**] at
10:50. The appointment is located at [**Last Name (NamePattern1) 439**] on the
ground floor. This is to discuss your antibiotics. Please call
[**Telephone/Fax (1) 457**] with any questions.
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2139-8-4**] at 10:35 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2139-8-4**] at 11:15 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
You have an appointment with Dr. [**Last Name (STitle) **] the neurosurgeon on
[**8-4**] at 1 PM in the [**Hospital **] Medical Office Building 3B.
ICD9 Codes: 486, 5990, 4439, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4693
} | Medical Text: Admission Date: [**2200-6-9**] Discharge Date: [**2200-6-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
CHIEF COMPLAINT: Chest pain/NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with [**Last Name (un) 2435**] placement
Swan ganz catheter placement
History of Present Illness:
Patient is an 85 yo M with h/o CAD s/p MI and 3 vessel CABG in
[**3-10**] (LIMA ->LAD, SVG -> LAD; D1, SVG -> RCA 40% stenosis per
cath in [**2198**]), CKD, bladder cancer with recent transurethral
resection of tumor on [**6-9**], complicated by SOB, chest pain, now
found to have NSTEMI who presents to the CCU for further
management of his ACS. For full details of prior hospital course
please refer to [**Hospital Unit Name 153**] notes. In brief, pt underwent successful
transurethral resection of his bladder tumor on [**6-9**]. However,
due to persistent bleeding he was put on CBI. The patient
subsequently suffered a vasovagal episode with SOB, increased 02
requirement, nausea/vomitting, and hypotension. Pt was treated
with nebs, steroids, vanco/zosyn for asthma/aspiration. His BP
improved with fluid boluses but was transferred to the [**Hospital Unit Name 153**] for
further observation.
.
In the [**Hospital Unit Name 153**], the patient's BP and and respiratory status
improved with the above interventions. He was also transfused 2
units PRBCs given his urinary clotting. However, prior to being
transferred to the floor the patient developed SSCP, SOB, and
bilateral arm pain. EKG demonstrated RBBB, inferior STT changes.
CK, MB, and troponin trended upwards. The patient was given
ASA/Plavix, heparin gtt, nitro gtt, metoprolol, and morphine.
Cardoiology was consulted who felt the patient was undergoing an
NSTEMI. Therefore, the patient was transferred to the CCU for
further care.
.
On arrival to the CCU, the patient feels well and was chest pain
free. He denied HA, dizziness/lightheadedness, diplopia, CP,
SOB, orthopnea, paroxysmal nocturnal dyspnea, nausea,
diaphoresis, leg pain.
.
On further review of symptoms, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. In the past he had episode of CP on exertion
with dyspnea. He can climb one flight of stairs.
.
Past Medical History:
1. CAD s/p MI w Vfib arrest/syncope and CABGx3 [**3-10**], no warning
symptoms, syncopized; EF [**10-12**] 45-50% on dobutamine stress echo,
followed by outside cardiologist. Cath in [**2198**] with 40% stenosis
of SVG -> RCA, otherwise patent grafts
2. Asthma: exacerbated by cats, coal, furnaces
3. Bladder cancer found [**5-15**] on cystoscopy, s/p transuretheral
resection on [**6-9**]
4. Gout
5. cataract surgery '[**97**], '[**99**]
6. cholecystectomy '[**89**]
7. TURP [**4-13**]
8. Depression
Social History:
Retired [**University/College **] Professor
Lives with wife
Quit smoking in [**2182**]
Former drinker
.
Family History:
Non-contributory, no history of early CAD
.
Physical Exam:
VS: T 96.5, BP 122/60, HR 85, RR 18, O2 95% on 2L NC
Gen: Pleasant talkative elderly male in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm. No bruits appreciated
CV: RRR, no m/r/g, nl S1 S2
Chest: Bibasilar crackles noted, no wheezing. symmetric
Abd: Soft, NT/ND + BS, no HSM.
Ext: No c/c/e. No femoral bruits. Ext warm and well perfused
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
.
Pertinent Results:
[**2200-6-9**] Bladder, biopsy:
A. Papillary urothelial carcinoma, high grade, with lamina
propria invasion. Muscularis propria is present and is free of
tumor.
B. Urothelial carcinoma in situ.
C. Squamous metaplasia, keratinized.
[**2200-6-12**]. Cardiac cath.
1. Selective coronary angiography of this right dominant system
demonstrated a three vessel native CAD. The LMCA had mild
disease with
moderate calcification. The LAD was occluded proximally. The
LCx was a
non-dominant vessel with a moderate diffuse disease. The RCA
was a
dominant vessle with a proximal 90% stenosis at the bifurcation
with the
AM.
2. Vein graft angiography revealed a patent SVG to the RCA.
There was
mild disease just distal to the touch down site. SVG to the D1
was
patent as well. Arterial conduit angiography initially could
not be
performed due to a tight left subclavian occlusion that was
likley
thrombotic in nature.
3. Resting hemodynamics revealed elevated right and left sided
filling
pressures with an RVEDP of 21 mmHg and a PAD pressure of 26 mm
Hg. The
cardiac index was depressed at 1.86 l/min/m2. There was a
moderate
systemic arterila hypertension with an SBP of 150 mmHg.
4. Left ventriculography was deferred given elevated creatinine.
5. Successful PCI/stent to proximal left subclavian thrombosis
with a
7.0x39mm Genesis stent deployed at 18atms and postdilated with a
9.0mm
balloon. Normal flow down vessel with no gradient across stent
at end of
procedure. There was a hazy 70% distal LAD lesion at the end of
the
case.
Echo. [**2200-6-12**]
Conclusions:
The left atrium is mildly dilated. The left ventricular cavity
size is normal. There is moderate regional left ventricular
systolic dysfunction with mid to distal anteroseptal akinesis,
apical akinesis/dyskinesis and mid to distal anterior
hypokinesis. No definite LV thrombus seen (but cannot
definitively exclude). Overall left ventricular systolic
function is moderately depressed. Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. 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. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is no pericardial
effusion.
Renal u/s [**2200-6-16**].
IMPRESSION: Thick-walled bladder with vascular flow. This most
likely
represents residual bladder tumor. No hydronephrosis.
[**6-17**]. Echo.
The left atrium is mildly dilated. There is mild to moderate
regional left ventricular systolic dysfunction with focal
dyskinesis of the apex and hypokinesis of the distal left
ventricle. The other segments contract well. No masses or
thrombi are seen in the left ventricle. Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened. There are mobile filamentous strands on the aortic
leaflets consistent with possible Lambl's excresences (normal
variant) although an aortic valve vegetation/mass cannot be
definitively excluded. 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.
Compared with the prior study (images reviewed) of [**2200-6-12**], the
left
ventricular function has slightly improved. No apical thrombus
is visualized. A small filamentous mobile lesion on the aortic
valve is present (seen on prior study but not mentioned) which
is consistent with probable Lambl's excrescence.
Brief Hospital Course:
In summary, this is an 85 yo M with CAD, s/p MI and 3 vessel
CABG in [**2194**], CKD, bladder tumor s/p recent transurethral
resection c/b [**Hospital 7792**] transferred to the CCU for further care.
NSTEMI/CAD. Patient with known CAD and previous history of MI
now with concerning EKG changes and positive cardiac enzymes.
Patient experienced vasovagal symptoms, n/v and chest pain/arm
pain all indicative of ACS. On the morning after he was
transferred to the CCU, the patient complained of [**9-17**]
substernal chest pain and chest pressure, with radiation of the
pain to his arms bilaterally, in the setting of pain/dysuria at
the distal penile urethra. Also complained of dyspnea,
confusion, no lightheadedness or dizziness. He was treated with
morphine, nitro drip, increased O2, and a nebulizer treatment
and the pain subsided. EKG showed new TWI in V2-V5.
Hemodynamically stable. He went urgently to the cath lab where
he was found to have a large, L subclavian thrombosis resulting
in decreased perfusion to the LIMA-LAD graft as well as distal
stenosis/haziness of the LAD. Bare metal stent was placed in the
L subclavian. During the remainder of the admission the patient
showed no further signs or symptoms of ischemia. The patient
was maintained on ASA 325mg daily, Plavix 75mg daily, integrilin
x 18hours post cath, heparin IV, Metoprolol, and Lipitor 80mg
(lipid panel adequate). Heparin and coumadin for prevention or
LV thrombus was held due to hematuria. Repeat ECHO prior to
discharge showed no sign of ventricular thrombus despite wall
motion abnormalities, and given risk of rebleeding from bladder,
anticoagulation was held on discharge.
Aspiration Pneumonia. Patient originally admitted to the [**Hospital Unit Name 153**]
with SOB thought to be related to vasovagal episode and possible
aspiration event versus asthma exacerabation. On [**6-10**] the
patient was started on broad spectrum levo/flagyl/vanc plan for
a total of 14 days due to concern of aspiration pneumonia given
setting of fever and leukocytosis. Patient was discharged home
off vanco, but to finish a total 14 day course of flagyl and
levofloxacin.
Anemia: Hct has trended down during admission in the setting of
urethral clotting from mid 30s to high 20s from a baseline of
35-40. Has required 3 units pRBCs with moderate response. On
[**6-14**], a CT of the abdomen and pelvis ruled out a retroperitoneal
bleed. However, CT showed the site of bleeding to be in the
bladder - on [**6-14**] 500cc of clot was irrigated by urology. They
continued to follow along and irrigate the bladder prn. Heparin
and coumadin were held during this episode of active bleeding. A
bladder ultrasound later showed residual tumor in the bladder
but no further blood clots. Bleeding resolved and CBI was able
to be discontinued prior to discharge.
Change in mental status. Patient exhibited some confusion and
waxing/[**Doctor Last Name 688**] mental status during his ICU stay. He was given a
1:1 sitter and ditropan was held. He was given prn Zydis.
Delerium resolved once patient stabilized.
Volume depletion. On [**6-14**] a swan ganz catheter was placed to more
closely assess the patient's volume status. He was found to have
volume depletion, which resolved with administration of IVF. The
SGC was pulled on [**6-15**] without complication.
Bladder resection: Pt is s/p bladder resection. He underwent
CBI with good effect. Repeat Bladder US showed residual tumor
in bladder. Foley catheter was initially removed but was
replaced on the day of discharge due to retention of ~ 400 cc in
the bladder; the patient's foley catheter is to remain in place
until evaluated at Dr.[**Name (NI) 6444**] office for voiding trial on
Monday, [**6-23**]. Coumadin and heparin were held in setting of
hematuria.
Gout: Currently asymptomatic. Given CKD, he was given
allopurinol every other day.
Hyperglycemia: Resolved, No h/o DM, cover with RISS in acute
setting.
Patient was discharged to rehabilitation facility with planned
cardiac follow-up with his cardiologist at the [**Hospital3 **] and
with urology for his bladder resection.
Medications on Admission:
Medications (outpatient):
ASA 81mg daily
Lipitor 10mg daily
Prilosec 20mg daily
Allopurinol 100mg daily
Centrum silver MVI daily
Buproprion 100mg daily
Discharge Medications:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for SOB.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
bladder cancer s/p bladder resection
coronary artery disease
acute coronary syndrome
hospital acquired pneumonia
acute on chronic renal insufficiency
anemia
Discharge Condition:
stable, breathing comfortably
Discharge Instructions:
Please call your physician if you experience fevers, chest pain,
abdominal pain, blood in the urine, dizzines, lightheadedness or
other concerning symptoms.
Followup Instructions:
Please return to Dr.[**Name (NI) 6444**] office at 319 [**Hospital1 1426**] on Monday,
[**2200-6-23**] at 1:15 pm for a voiding trial. Until that time,
you should keep your foley catheter in place.
We have also scheduled you a follow-up appointment with a nurse
practitioner in Dr.[**Name (NI) 6444**] Urology office on [**Last Name (LF) 2974**], [**2200-7-11**] at 10:00a.m. for BCG therapy. Please call ([**Telephone/Fax (1) 6441**] if
there is a problem with this appointment.
You have a follow-up appointment with your cardiologist, Dr.
[**Last Name (STitle) 20391**], [**Telephone/Fax (1) 20392**] on [**2200-7-22**] at 10:00a.m. Please
call to reschedule if you are unable to keep this appointment.
Please schedule follow-up with your primary care physician
within the next 2 weeks.
ICD9 Codes: 9971, 2851, 4280, 5070, 2930, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4694
} | Medical Text: Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-23**]
Date of Birth: [**2054-1-30**] Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Abd pain and N/V
Major Surgical or Invasive Procedure:
s/p right and left hemicolectomy
History of Present Illness:
60F with ESRD s/p deceased donor renal transplant, HTN, and
diverticulitis who was initially admitted for worsening
abdominal pain and N/V and now presents to the [**Hospital Unit Name 153**] with
hypotension after having a n ex-lap and bowel resection for a
perforated cecum. She has had approximately 3 episodes of
diverticulitis in the past year which resolved with antibiotics.
She was planning to have an elective outpatient laparoscopic
colectomy given her frequent flares. Prior to this admission,
she reportedly had intermittent [**10-3**] abdominal pain in the RLQ
and LLQ and significant nausea and vomiting, she was unable to
keep down any POs for 48 hours prior to admission. This felt
worse than her prior diverticulitis flares and she was admitted
for observation, hydration, and antibiotics. CT abd/pelvis at
admission showed pericolonic stranding but no e/o
diverticulitis.
Since admission to the surgery service, she was staretd on Cipro
and Flagyl for the colitis seen on CT. Her abdominal pain
acutely worsened on [**5-12**] and she described feeling a "[**Doctor Last Name **]" in
her abdomen. A repeat CT abd/pelvis showed perforation at the
cecum with free air present and extravasation of PO contrast
into the peritoneum. She was taken to the OR for a ex-lab where
she was found to have a stricture in the signoid colon and a
perforation in her cecum with spillage of stool in to the
peritoneum. She underwent a right and left colectomy, the
transverse colon was left in place but is discontinusous. Her
abdomen was left open after the procedure.
Past Medical History:
Hypertension
End-stage renal disease, etiology unclear
Dyslipidemia
Left knee patellar fracture
Septic arthritis of the knee [**10/2109**]
Bone spur left foot
Neck/shoulder pain
Diverticula
UTI: cipro resistant E.coli
Anemia: started Aranesp [**2112-7-4**]
Past Surgical History:
S/p deceased donor renal transplantation on [**2096-2-27**]
S/p Bilateral reduction mammoplasties [**7-/2112**]
Social History:
Married. Has three children. She is a fourth grade teacher in
inner city [**Location (un) 86**]. Does not smoke, drinks rarely.
Family History:
Father, brother, and oldest son with diverticulitis. No history
of colon cancer. Mother died of MI. Denies family history of
renal disease or cancer. History of hypertension and
diverticulitis in brother. Father had heart failure and a
pacemaker.
Physical Exam:
Admission Physical Exam:
Vitals: T 94.3, BP 148/106, HR 91, RR 14, SpO2 100%
General: Intubated, sedated
HEENT: ET and OG tubes in place
Neck: Right IJ in place, site is c/d/i
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: distended, firm and surgically open
GU: Foley in place
Ext: Warm, well perfused, no edema
Neuro: intubated and sedated, not arousable and not following
commands.
Discharge Physical Exam:
General: Patient appears well, alert and oriented, ambulating
with contact [**Name (NI) 1118**], requires assistance for ADLs, pain
controlled with oral pain medicaiton regimen. + liquid brown
stool and gas in ileostomy apppliance.
VS: 98.1, 97.9, 70, 142/84, 16, 99% RA
Neuro: A&OX3
Lungs: CTAB
Cardiac: RRR
Abd: flat, non-distended, midline incision intact with staples
and retention sutures, ileostomy pink with stool and gas
Lower Extremities: Appear very deconditioned, weak bilaterally,
gait intact
Pertinent Results:
ADMISSION LABS:
[**2114-5-11**] 10:35AM BLOOD WBC-14.8* RBC-4.14* Hgb-11.4* Hct-36.2
MCV-87 MCH-27.6 MCHC-31.5 RDW-13.7 Plt Ct-513*
[**2114-5-11**] 10:35AM BLOOD Neuts-90.3* Lymphs-6.9* Monos-2.4 Eos-0.2
Baso-0.2
[**2114-5-12**] 09:23PM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2114-5-13**] 04:34AM BLOOD PT-13.2* PTT-30.0 INR(PT)-1.2*
[**2114-5-11**] 10:35AM BLOOD Glucose-114* UreaN-49* Creat-1.9* Na-141
K-3.6 Cl-105 HCO3-21* AnGap-19
[**2114-5-11**] 10:35AM BLOOD ALT-9 AST-16 AlkPhos-53 TotBili-0.2
[**2114-5-11**] 10:35AM BLOOD Lipase-24
[**2114-5-12**] 05:53AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
[**2114-5-13**] 04:49AM BLOOD Type-ART pO2-178* pCO2-33* pH-7.41
calTCO2-22 Base XS--2
[**2114-5-14**] bcx ngtd
[**2114-5-13**] ucx negative
[**2114-5-13**] bcx negative
[**2114-5-11**] bcx x2 negative
PORTABLE ABDOMEN Study Date of [**2114-5-12**] 8:07 PM
Supine and decubitus view of the abdomen shows pneumoperitoneum,
not present on the abdomen CT [**5-11**], but detected on the chest
radiograph
performed concurrently and reported prior to review of this
study. Retained contrast [**Doctor Last Name 360**] in the cecum shows its diameter
is 8 cm. Proximal to it, the small bowel is moderately
distended to a diameter of 28 mm. A subsequent abdominal CT
scan also available at the time of this review shows the effects
of likely cecal perforation.
IMAGING:
-[**5-12**] CT Abd:
IMPRESSION:
1. There is evidence of new bowel perforation at the level of
the cecum, with evidence of new free air, free fluid, as well as
extraluminal oral contrast surrounding the cecum. Surgical
consultation is recommended.
2. Pericolonic stranding is again noted diffusely throughout
the colon and greatest throughout the descending and sigmoid
colon. These findings are most consistent with diffuse colitis
which has likely led to perforation.
3. New small bilateral pleural effusions
Cardiovascular Report ECG Study Date of [**2114-5-14**] 11:12:58 AM
Sinus rhythm with low amplitude P waves. Low QRS voltage
throughout.
Delayed R wave transition. Diffuse non-specific T wave
flattening. Compared to the previous tracing of [**2112-7-15**] the
voltage is lower. P wave amplitude has decreased. Diffuse T wave
flattening is present. Clinical correlation is suggested.
CHEST (PORTABLE AP) Study Date of [**2114-5-15**] 3:19 AM
No acute cardiopulmonary process. Low endotracheal tube
position.
[**2114-5-19**] 05:56AM BLOOD WBC-12.4* RBC-3.25* Hgb-9.0* Hct-28.1*
MCV-86 MCH-27.6 MCHC-32.0 RDW-14.2 Plt Ct-264
[**2114-5-18**] 03:58AM BLOOD WBC-19.2* RBC-3.50* Hgb-9.7* Hct-29.7*
MCV-85 MCH-27.8 MCHC-32.7 RDW-14.4 Plt Ct-259
[**2114-5-17**] 02:00AM BLOOD WBC-21.4* RBC-3.30* Hgb-9.3* Hct-27.9*
MCV-85 MCH-28.3 MCHC-33.4 RDW-14.7 Plt Ct-284
[**2114-5-16**] 04:22PM BLOOD WBC-22.0* RBC-3.25* Hgb-9.1* Hct-28.2*
MCV-87 MCH-28.1 MCHC-32.5 RDW-15.7* Plt Ct-269
[**2114-5-16**] 02:25AM BLOOD WBC-21.2* RBC-2.96* Hgb-8.9* Hct-25.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-14.7 Plt Ct-226
[**2114-5-15**] 01:59PM BLOOD WBC-22.3* RBC-3.09* Hgb-8.8* Hct-26.8*
MCV-87 MCH-28.4 MCHC-32.7 RDW-15.0 Plt Ct-241
[**2114-5-15**] 08:46AM BLOOD WBC-21.9* RBC-2.73* Hgb-7.6* Hct-23.6*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.1 Plt Ct-257
[**2114-5-15**] 02:41AM BLOOD WBC-21.3* RBC-2.45* Hgb-6.8* Hct-21.4*
MCV-87 MCH-27.6 MCHC-31.7 RDW-14.0 Plt Ct-328
[**2114-5-14**] 08:28PM BLOOD WBC-20.8* RBC-2.50* Hgb-7.1* Hct-22.0*
MCV-88 MCH-28.4 MCHC-32.2 RDW-15.0 Plt Ct-318
[**2114-5-14**] 08:28PM BLOOD WBC-20.8* RBC-2.50* Hgb-7.1* Hct-22.0*
MCV-88 MCH-28.4 MCHC-32.2 RDW-15.0 Plt Ct-318
[**2114-5-14**] 04:00AM BLOOD WBC-23.2* RBC-3.15* Hgb-8.7* Hct-27.4*
MCV-87 MCH-27.6 MCHC-31.7 RDW-13.9 Plt Ct-355
[**2114-5-13**] 05:20PM BLOOD WBC-21.8*# RBC-3.35* Hgb-9.3* Hct-29.0*
MCV-87 MCH-27.9 MCHC-32.2 RDW-14.7 Plt Ct-420
[**2114-5-13**] 04:34AM BLOOD WBC-3.7*# RBC-3.82* Hgb-10.7* Hct-32.8*
MCV-86 MCH-28.0 MCHC-32.5 RDW-13.5 Plt Ct-512*
[**2114-5-12**] 05:53AM BLOOD WBC-12.4* RBC-3.43* Hgb-9.6* Hct-29.4*
MCV-86 MCH-27.9 MCHC-32.6 RDW-13.5 Plt Ct-453*
[**2114-5-11**] 10:35AM BLOOD WBC-14.8* RBC-4.14* Hgb-11.4* Hct-36.2
MCV-87 MCH-27.6 MCHC-31.5 RDW-13.7 Plt Ct-513*
[**2114-5-18**] 03:58AM BLOOD Neuts-89.1* Lymphs-6.2* Monos-4.2 Eos-0.4
Baso-0.1
[**2114-5-17**] 02:00AM BLOOD Neuts-94.0* Lymphs-3.3* Monos-2.4 Eos-0.3
Baso-0
[**2114-5-16**] 02:25AM BLOOD Neuts-95.7* Lymphs-2.1* Monos-2.2 Eos-0.1
Baso-0
[**2114-5-14**] 04:00AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2114-5-13**] 05:20PM BLOOD Neuts-67 Bands-28* Lymphs-3* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2114-5-14**] 04:00AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+
[**2114-5-13**] 05:20PM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL
[**2114-5-13**] 04:34AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2114-5-12**] 09:23PM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2114-5-19**] 05:56AM BLOOD Plt Ct-264
[**2114-5-18**] 03:58AM BLOOD Plt Ct-259
[**2114-5-18**] 03:58AM BLOOD PT-10.2 PTT-25.3 INR(PT)-0.9
[**2114-5-17**] 02:00AM BLOOD Plt Ct-284
[**2114-5-17**] 02:00AM BLOOD PT-9.9 PTT-26.0 INR(PT)-0.9
[**2114-5-16**] 04:22PM BLOOD Plt Ct-269
[**2114-5-16**] 02:25AM BLOOD Plt Ct-226
[**2114-5-16**] 02:25AM BLOOD PT-10.6 PTT-30.2 INR(PT)-1.0
[**2114-5-22**] 06:00AM BLOOD Creat-1.1
[**2114-5-21**] 06:00AM BLOOD Creat-1.2*
[**2114-5-20**] 06:05AM BLOOD Glucose-80 UreaN-25* Creat-1.0 Na-138
K-3.9 Cl-101 HCO3-27 AnGap-14
[**2114-5-19**] 05:56AM BLOOD Glucose-59* UreaN-28* Creat-1.1 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
[**2114-5-18**] 03:58AM BLOOD Glucose-77 UreaN-34* Creat-1.1 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
[**2114-5-17**] 02:00AM BLOOD Glucose-88 UreaN-36* Creat-1.5* Na-142
K-4.1 Cl-113* HCO3-18* AnGap-15
[**2114-5-16**] 02:25AM BLOOD Glucose-74 UreaN-38* Creat-2.0* Na-140
K-4.1 Cl-114* HCO3-20* AnGap-10
[**2114-5-15**] 01:59PM BLOOD Glucose-80 UreaN-35* Creat-2.1* Na-138
K-4.7 Cl-112* HCO3-19* AnGap-12
[**2114-5-20**] 06:05AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.5*
[**2114-5-19**] 05:56AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
[**2114-5-18**] 03:58AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
[**2114-5-17**] 08:15PM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2
[**2114-5-17**] 02:00AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0
[**2114-5-16**] 02:25AM BLOOD Calcium-7.5* Phos-4.5 Mg-2.3
[**2114-5-15**] 01:59PM BLOOD Calcium-7.4* Phos-5.1* Mg-2.3
[**2114-5-15**] 02:41AM BLOOD Albumin-1.7* Calcium-7.2* Phos-4.5 Mg-2.2
[**2114-5-14**] 08:28PM BLOOD Calcium-7.0* Phos-4.3 Mg-2.1
[**2114-5-14**] 12:51PM BLOOD Calcium-7.1* Phos-4.3 Mg-2.3
[**2114-5-14**] 04:00AM BLOOD Calcium-7.3* Phos-3.7 Mg-2.3
[**2114-5-13**] 04:34AM BLOOD Calcium-7.0* Phos-2.4* Mg-2.0
[**2114-5-12**] 05:53AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
[**2114-5-22**] 06:00AM BLOOD Vanco-12.9
[**2114-5-21**] 06:00AM BLOOD Vanco-13.8
[**2114-5-20**] 06:05AM BLOOD Vanco-11.5
[**2114-5-19**] 03:36PM BLOOD Vanco-13.6
[**2114-5-19**] 05:56AM BLOOD Vanco-19.9
[**2114-5-18**] 06:12AM BLOOD Vanco-15.8
[**2114-5-19**] 03:36PM BLOOD Cyclspr-112
[**2114-5-18**] 03:58AM BLOOD Cyclspr-259
[**2114-5-17**] 02:00AM BLOOD Cyclspr-45*
[**2114-5-14**] 04:00AM BLOOD Cyclspr-111
[**2114-5-13**] 04:34AM BLOOD Cyclspr-200
[**2114-5-12**] 05:53AM BLOOD Cyclspr-93*
[**2114-5-17**] 04:33AM BLOOD Type-ART pO2-125* pCO2-38 pH-7.39
calTCO2-24 Base XS--1
[**2114-5-16**] 08:58AM BLOOD Type-ART Temp-36.8 Rates-0/8 Tidal V-800
FiO2-40 pO2-153* pCO2-36 pH-7.28* calTCO2-18* Base XS--8
Intubat-INTUBATED
[**2114-5-15**] 08:45PM BLOOD Type-ART Temp-36.8 Rates-10/ PEEP-5
pO2-149* pCO2-41 pH-7.27* calTCO2-20* Base XS--7 -ASSIST/CON
Intubat-INTUBATED
[**2114-5-15**] 02:13PM BLOOD Type-ART pO2-176* pCO2-33* pH-7.33*
calTCO2-18* Base XS--7
[**2114-5-15**] 11:36AM BLOOD Type-MIX Comment-GREEN TOP
[**2114-5-15**] 11:33AM BLOOD Type-ART pO2-140* pCO2-46* pH-7.21*
calTCO2-19* Base XS--9
[**2114-5-15**] 03:09AM BLOOD Type-ART pO2-172* pCO2-30* pH-7.39
calTCO2-19* Base XS--5
[**2114-5-14**] 08:48PM BLOOD Type-ART pO2-123* pCO2-30* pH-7.35
calTCO2-17* Base XS--7
[**2114-5-14**] 01:22PM BLOOD Type-ART pO2-171* pCO2-36 pH-7.30*
calTCO2-18* Base XS--7
Brief Hospital Course:
Mrs. [**Known lastname 1119**], a patient known to the colorectal surgery service,
presented to the emergency department on [**2114-5-11**] with nausea,
vomiting, and abdominal pain. She was diagnosed with
diverticulitis and she was evaluated by the acute care service
in the emergency department and a plan was formulated with Dr.
[**Last Name (STitle) 1120**] to admit the patient for abdominal exams, antibiotics and
rehydration with plan to monitor and expedite surgical plans
based on her medical history and sudden relapse of symptoms
while on outpatient antibiotic therapy. Nephrology was consulted
for advice related to immunosuppression medications and past
renal transplant and followed the patient for the duration of
her inpatient admission. On [**2114-5-12**] the patient was monitored
closely. She was started on a clear liquid diet and was given a
Dulcolax Supp x1 and had 2 bowel movements. She remained
distended and was given a dose of milk of magnesia. The patient
was improving when she had a sudden onset of abdominal pain. CT
revealed extravasation of contrast and she was taken to the
operating room with Dr. [**Last Name (STitle) **] for exploratory laparotomy and
two segmental colectomies, was left with open abdomen and
disconnected and because of the difficult case and condition of
bowel as described in the operative note, the patient was
transferred to the intensive care unit appropriate drains. On
[**2114-5-14**] the patient returned to the operating room with Dr.
[**Last Name (STitle) **] after stabilization in the ICU for washout, completion
proctectomy and colectomy, ileostomy and closure of the abdomen
with retention sutures and staples. The patient was transferred
to the [**Hospital Unit Name 153**] and the course of ICU care is described below.
[**Hospital Unit Name 153**] Course per [**Hospital Unit Name 153**] resident:
60F with ESRD s/p deceased renal transplant in [**2095**] on
immunosuppression, HTN and h/o diverticulitis who presented to
the [**Hospital Unit Name 153**] with hypotension after ex-lap with right/left
hemicolectomy performed for cecal perforation and sigmoid
stricture.
.
#Cecal perforation s/p colectomy: The cause of her perforation
was thought to be a sigmoid stricture which was found
intraoperatively, likely related to her multiple episodes of
diverticulitis. She had a primary anastomosis and loop
ileostomy. She was commenced on vanc/Zosyn for an 8 day course
per surgery, and was maintained on a morphine PCA prn. She was
intubated for the procedure, but was quickly and successfully
weaned off of the vent prior to callout to the surgical floor.
.
# Hypertension ?????? Her initial hypotension resolved, and her home
anti-hypertensives were recommenced due to her hx of HTN.
.
#ESRD s/p renal transplant: renal transplant recs were followed,
and after her procedure, she was restarted on azathioprine, and
transitioned to a 5mg daily dose of prednisone. She was
restarted on cyclosporine per renal transplant on [**5-17**]. .
#Non-anion gap metabolic acidosis: Resolved. Likely related to
volume resuscitation with NS. Chloride is also elevated which
supports this.
.
#Anemia: Hct trending down almost 10 points compared to her
pre-op CBC. Likely from blood loss during her colectomy as well
as dilutional effect from multiple fluid boluses. She was also
hemoconcentrated at admission from poor PO intake and has
baseline anemia with Hct in the 24-32 range from her ESRD s/p
transplant. She was transfused with packed red blood cells. She
was monitored closely.
The patient was extubated and started on a clear liquid diet on
[**2114-5-17**].
Surgical Floor Course:
The patient was transferred to the inpatient floor on [**2114-5-18**]
and began a regular diet. She was continued on her antibiotic
course. [**2114-5-19**] the Foley was removed at midnight. The patient
had temporary central venous access which was not ideal for the
floor and because of intravenous antibiotics and the patient's
access status unable to place PICC line after multiple
attempts. IR was unable to schedule the patient for IR placement
of the PICC line. The nursing staff continued to use the CVL for
access. On [**2114-5-20**] the patient was voiding. She was given
vancomycin 500x1, troughs were monitored closely at the patient
was a renal transplant patient and she was strated on pain
medications by mouth. [**2114-5-21**] Renal transplant fellow:
recommend continuing home dose of immunosuppression medications.
JP drains were removed. The patient was meeting discharge
criteria. She was followed closely throughout her admission by
the wound/ostomy nursing team as well as physical therapy. After
consultation with the nephrology team the patient was started on
a 14 day course of Augmentin started and fluconazole and Zosyn
were discontinued. The PICC line was pulled back to midline
position and the central venous line was removed without issue.
Her cyclosporine trough was monitored closely throughout her
hospitalization as there was a risk of interaction with
fluconazole. Her last trough was 112 on [**2114-5-19**]. She continued
her Cyclosporine and was discharged on appropriate dosing. The
patient was ordered to have the Cyclosporine trough measured
prior to the morning dose on [**2114-5-24**] and dose adjustment with
assistance of the renal transplant center. Arrangements were
arranged for the patient to be transferred to a rehabilitation
facility appropriately as she had become deconditioned. The
midline catheter was removed at time of discharge.
Medications on Admission:
Medications at home:
AZATHIOPRINE - (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
CIPROFLOXACIN [CIPRO] - 500 mg Tablet - 1 Tablet(s) by mouth
twice a day
CYCLOSPORINE MODIFIED [NEORAL] - (Prescribed by Other Provider)
- 100 mg Capsule - one Capsule(s) by mouth twice daily
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily
METRONIDAZOLE - 500 mg Tablet - 1 Tablet(s) by mouth three times
a day
PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet -
one
Tablet(s) by mouth evert other day
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - 160 mg-12.5 mg
Tablet - 1 Tablet(s) by mouth twice a day
Medications - OTC
CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] -
(Prescribed by Other Provider) - 600 mg-400 unit Tablet - one
Tablet(s) by mouth twice daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours): Please check cyclosporin true 12 hour
trough prior to morning dose on [**2114-5-24**]. Goal is between 50-100.
5. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 5 days: Do not drink alcohol or
drive a car while taking this medication. . Tablet(s)
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 days: To complete 14 day
course. Startd therapy [**2114-5-22**], lsat day of therapy [**2114-5-4**].
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Sigmoid diverticulitis with abscess and stricture, perforated
cecum
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 a laparoscopic
Colectomy for surgical management of your diverticulitis.
Unfortunately after this procedure you were found to have a
stricture and leaking into your abdomen which required you to be
taken back to the operating room for a completion colectomy and
end ileostomy. Closure of the surgical incision required
placement of retention sutures which remain in place and will
stay in place along with the staples until you return for your 2
weeks post-operative visit. You have recovered from this
procedure and you are now ready to return home. Samples from
your colon were taken and this tissue has been sent to the
pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you regarding these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery. It is important that you continue to
have your immunosupression medications monitored for your kidney
transplant. Please have your level checked at rehab the morning
of [**2114-5-24**] and the goal of the cyclosporin level is 50-100. The
rehab should fax this level to the renal transplant office after
it is back for recommendations at [**Telephone/Fax (1) 697**]. This will be
ordered in your paperwork however, it is the facilities
responsibility to order the test.
Please monitor your bowel function closely. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, elevated ileostomy
output. You have a new ileostomy. The most common complication
from a new ileostomy placement is dehydration. The output from
the stoma is stool from the small intestine and the water
content is very high. The stool is no longer passing through the
large intestine which is where the water from the stool is
reabsorbed into the body and the stool becomes formed. You must
measure your ileostomy output for the next few weeks. The output
from the stoma should not be more than 1200cc or less than
500cc. If you find that your output has become too much or too
little, please call the office for advice. The office nurse or
nurse practitioner can recommend medications to increase or slow
the ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If you notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. You may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to you by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own. The bridge will be removed from the
ileostomy at your follow-up appointment with the wound/ostomy
nurses.
You have a long vertical incision on your abdomen that is closed
with staples and retention sutures. This incision can be left
open to air or covered with a dry sterile gauze dressing if the
staples become irritated from clothing. The staples will stay in
place until your first post-operative visit at which time they
can be removed in the clinic, most likely by the office nurse.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. [**Last Name (STitle) **]. You must continue to wear the
abdomoinal binder with a whole cut for the ileostomy to fit
under at least until your second post-operative visit with Dr.
[**Last Name (STitle) **]. He will give you further instructions at this time.
You will be prescribed a small amount of the pain medication
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please call the colorectal surgery clinic at [**Telephone/Fax (1) 160**] to
make an appointment for follow-up with [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP for 2
weeks after discharge. At this appointment your second
post-operative visit with Dr. [**Last Name (STitle) **] will be arranged.
Please call the would ostomy nurses to arrange an appointment 1
week after discharge. At this appointment, the brdige will be
removed from the ileostomy.
Department: RADIOLOGY
When: TUESDAY [**2114-9-11**] at 3:30 PM
With: RADIOLOGY [**Telephone/Fax (1) 1125**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
You have the following appointments previously arranged for you
in the [**Hospital1 18**] System:
Department: RADIOLOGY
When: TUESDAY [**2114-9-11**] at 3:00 PM
With: RADIOLOGY [**Telephone/Fax (1) 1125**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: RADIOLOGY
When: TUESDAY [**2114-9-11**] at 2:30 PM
With: RADIOLOGY [**Telephone/Fax (1) 1125**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2114-5-23**]
ICD9 Codes: 0389, 5845, 2851, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4695
} | Medical Text: Admission Date: [**2106-11-5**] Discharge Date: [**2106-11-16**]
Date of Birth: [**2051-9-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old man
who presented to the [**Hospital6 256**] to
the Emergency Department following a fall approximately 16 ft
from a roof. He landed on his back. There was no loss of
consciousness. He complained of pelvic pain and lower back
pain. Initial evaluation at the outside hospital showed
evidence of an L2 compression fracture.
Upon transfer to the [**Hospital6 256**], he
was evaluated by the Trauma Surgery Service, and extensive
work-up was performed. This examination showed evidence on
plain film of right pubic rami fracture. CT scan showed no
evidence of cervical spine or thoracic spine damage; however,
there was an L2 burst fracture seen.
Based on this, he was admitted to [**Hospital3 **] and managed
jointly by the Trauma Surgery Service and Orthopedic Surgery
Service.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: Prinivil unknown dosage.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is a social drinker and drinks
approximately 1-2 packs a day.
PHYSICAL EXAMINATION: Vital signs: Upon presentation, the
patient was afebrile and stable. General: He was alert and
oriented times three with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15. HEENT:
Pupils were equal and reactive to light. Tympanic membranes
clear. There was some small facial lacerations on his chin
and over the bridge of his nose. Trachea was noted to be
midline. Lungs: Clear to auscultation bilaterally. Heart:
Regular, rate and rhythm. No murmurs, rubs, or gallops.
Abdomen: Soft. He was tender to deep palpation.
Extremities: No evidence of deformities. Palpable pulses
throughout. Rectal: Normal sphincter tone. Heme negative.
Pelvis: Stable but tender over right iliac symphysis. Back:
Tender over the lumbar spine; however, without any stepoffs.
LABORATORY DATA: On presentation CHEM7 was with a sodium of
139, potassium 4.1, chloride 103, CO2 27, BUN 4, creatinine
0.8, glucose 110; PT 11.9, PTT 20.6, INR 1.0; other
laboratory values were within normal limits.
HOSPITAL COURSE: On the evening of [**2106-11-4**], the
patient was taken to the Operating Room for repair and
instrumentation of his L2 burst fracture. Surgery was
uncomplicated; however, during the course of instrumentation,
there was considerable bleeding through an epidural vein.
Base on this, the patient ultimately required greater than 20
U of blood products. Nevertheless, he tolerated the surgery
quite well and was transferred to the Postanesthesia Care
Unit intubated.
From there, he was transferred to the Surgical Intensive Care
Unit intubated and was stable over night. On hospital day
#3, on postoperative day #2, the patient was extubated, again
without any incident, and later on that same day was actually
moved to the regular surgical floor.
The clinical course over the next 72 hours was unremarkable.
We focused mainly on diuresis, in that the patient was up
approximately 16 L at that point. This proceeded without any
complications. The patient had a urine output of greater
than 2.5 L/day, but otherwise vital signs remained quite
stable.
The plan at that point was for the patient to return to the
Operating Room on [**2106-11-12**], for completion of his
back surgery and placement of additional instrumentation.
This again proceeded without any complications. The patient
is not requiring any additional blood products and was moved
to the Postanesthesia Care Unit and extubated again without
complications.
On the morning of on postoperative day #1 from the second
procedure, the patient was moved to the surgical floor, and
again vital signs remained stable.
Over the next 48 hours, the patient did extremely well with
Physical Therapy. He was fitted for a TSLO brace, which he
will wear going forward. Given the possible exposure of
hardware contaminant, the patient was given a two-week course
of Cephazolin. To achieve this, a PICC line was placed on
[**2106-11-14**].
On [**2106-11-16**], after evaluation by Physical Therapy,
the Orthopedic Team and the attending surgeon, it was deemed
that the patient was appropriate for discharge, and
arrangements were made.
DISCHARGE DIAGNOSIS:
1. Status post L2 burst fracture.
2. Right inferior pubic rami fracture.
3. Right sacral fracture.
DISPOSITION: The patient is discharged to home with
services. He is in stable condition and is required to wear
the TSLO brace.
DISCHARGE MEDICATIONS: Folic Acid, Thiamine, Darvocet-N 100
dispense #20 [**1-7**] tab to be taken q.4-6 hours, Darvocet-N 100
dispense #40 [**1-7**] tab q.4-6 hours as needed for severe pain,
OxyContin 20 mg b.i.d., Cephazolin 1 g IV q.8 hours for 3
weeks, Dulcolax 100 mg p.o. b.i.d.
FOLLOW-UP: He will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] in the
clinic in three weeks at which time he can be assessed for
stability of his fracture and placement of hardware. At that
time, the PICC line can also be removed.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 50169**]
MEDQUIST36
D: [**2106-11-16**] 20:00
T: [**2106-11-16**] 14:03
JOB#: [**Job Number 50170**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4696
} | Medical Text: Admission Date: [**2177-5-26**] Discharge Date: [**2177-5-30**]
Date of Birth: [**2123-5-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2177-5-26**] Coronary artery bypass graft x 3 LIMA-> LAD, RSVG->
Diagonal, PLV
History of Present Illness:
Mr. [**Known lastname 1511**] is a 53 year old man with stable angina found to have
multi-vessel disease.
Cardiac Catheterization: Date:[**2177-4-17**] Place:MW
subtotal occlusion od LAD, 80% stenosis of ostium of PDA,
occluded PDA, patent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] in obtuse marginal and mid RCA
Cardiac Echocardiogram:[**2176-3-25**] EF 55% with no wall motion
abnormalities, 1+MR, trace AI, 1+TR, 1+PI
Other diagnostics:ETT:angina at 9 minutes w associated
diagnostic
ST changes
Past Medical History:
Coronary artery disease s/p cypher DES to LCx and R-PLV in [**2172**]
Hyperlipidemia
Ulcerative colitis
Lumbar disc disease s/p lumbo-sacral surgery [**2176**]
s/p Appendectomy
s/p Hernia repair [**2172**]
Social History:
Race:caucasian
Last Dental Exam:>1 year ago
Lives with:alone, has girlfriend
Occupation: repair diesel engines at a golf course
Tobacco:denies
EtOH:4 beers/month
Family History:
Father w CABG in his 70's
Physical Exam:
Pulse:72 Resp:16
B/P Left: 126/90
Height:5'9" Weight:82 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2177-5-26**] Echo: Pre CPB: No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. Dr.
[**Last Name (STitle) **] was notified in person of the results.
Post CPB:
The patient is in sinus rhythm. The biventricular systolic
function is unchanged. The visible contours of the thoracic
aorta are intact.
[**2177-5-29**] 10:45AM BLOOD WBC-8.5 RBC-3.19* Hgb-10.3* Hct-29.5*
MCV-93 MCH-32.2* MCHC-34.8 RDW-13.7 Plt Ct-156
[**2177-5-29**] 10:45AM BLOOD Na-139 K-4.5 Cl-101
[**2177-5-28**] 04:13AM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-136
K-4.2 Cl-103 HCO3-27 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 1511**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**5-26**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 3. See operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one he was started on beta-blockers and diuresed towards his
pre-op weight. Later this day he was transferred to the
step-down floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with VNA serives in good condition with appropriate follow
up instructions.
Medications on Admission:
Asacol 800 mg [**Hospital1 **]
Aspirin 325 mg daily
Pravastatin 40 mg daily
Metoprolol tartrate 25 mg [**Hospital1 **]
Fish oil
Multivitamin
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x
Past medical history:
s/p cypher DES to LCx and R-PLV in [**2172**]
Hyperlipidemia
Ulcerative colitis
Lumbar disc disease s/p lumbo-sacral surgery [**2176**]
s/p Appendectomy
s/p Hernia repair [**2172**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**6-19**] at 1:30pm
Cardiologist: Dr. [**Last Name (STitle) 6254**] on [**7-1**] at 9:00am
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70216**] in [**4-15**] weeks [**Telephone/Fax (1) 72189**]
**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:[**2177-5-30**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4697
} | Medical Text: Admission Date: [**2115-11-21**] Discharge Date: [**2116-1-13**]
Date of Birth: [**2046-3-31**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
69 year old female admitted from outside hospital with right
upper quandrant abdominal pain. Status post ERCP and
sphicterotomy where a stone was removed. Febrile and elevated
white count now.
Major Surgical or Invasive Procedure:
Status post placement of two retroperitoneal drains on [**11-16**] and
[**11-22**].
History of Present Illness:
HPI: 69F h/o chronic steroid use (initially prenisone 60mg
daily, now tapered to 2.5mg daily.for uveitis and retinitis who
initially presented to [**Hospital3 17921**] Center on [**11-9**] with
severe back pain radiating to the RUQ and epigastric region that
started at 11AM the same day of presentation. She reported
vomiting and nausea associated with the pain. She was thought to
have acute calculus cholecystitis after US (gallstones and
thickened gallbladder wall with dilated CBD) and underwent ERCP
on [**2115-11-11**] which was reported as a successful sphincterotomy
and removal of diminutive stone material. Her initial admission
WBC was 9.6 on admission and on transfer was 18.8. She continued
to have persisitent fevers post-procedure and a CT scan done on
[**11-14**] demonstarted a large retroperitoneal fluid collection. On
[**11-16**], she underwent IR drainage with placement of a drain in
her retroperitoneal fluid collection with drainage of dark brown
fluid, which later cultures [**Female First Name (un) 564**]. Fluid analysis had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
2253, prot 2.6, glucose 4, LDH 5945. Her initial LFTs had AST
661, ALT 521, AP 390, Albumin 3.8. Last LFTs [**11-21**] AP 362, AST
22, ALT 25, T.bili 0.4, [**Doctor First Name **] 104, lip 467. It was decided that
the patient continued fevers, rising WBC, and presistent fluid
collection, the patient was transferred to [**Hospital1 18**].
Past Medical History:
Hypertension
Uveitis
Retinitis
Social History:
Positive for tobacco in past.
Occasional alcohol use
Married lives with husband in [**Name (NI) 3844**]
Family History:
NC
Physical Exam:
T: 99.0 (102.2) P: 90-112 R: 18 95% RA BP: 140-150/60-70 Wt:
67.1kg FS 130-170
General: Nausea, spitting into bucket.
HEENT: ?Oral thrush with adherent white coating on the anterior
tongue.
Neck: {X}WNL
Cardiovascular: {X}WNL
Respiratory: {X}WNL
Back: 2 RP drain sites clean and dry.
Gastrointestinal: Hypoactive bowel sounds. Tender to palpation
in
the RUQ.
Genitourinary: {X}WNL
Musculoskeletal: {X}WNL
Skin: {X}WNL
Neurological: Left eye visual field deficits as at baseline.
Psychiatric: {X}WNL
Heme/Lymph: {X}WNL
Other: Right subclavian site clean and dry, nontender, no
erythema.
Pertinent Results:
[**2115-12-1**] 10:10AM BLOOD WBC-21.1*# RBC-3.77*# Hgb-10.8*#
Hct-33.4*# MCV-89 MCH-28.6 MCHC-32.3 RDW-15.5 Plt Ct-732*
[**2115-11-29**] 09:15AM BLOOD WBC-13.5* RBC-3.11* Hgb-9.0* Hct-26.5*
MCV-85 MCH-28.8 MCHC-33.7 RDW-15.2 Plt Ct-485*
[**2115-11-27**] 05:25AM BLOOD WBC-12.7* RBC-3.09* Hgb-9.0* Hct-26.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-570*
[**2115-11-22**] 12:04AM BLOOD WBC-20.7* RBC-3.37* Hgb-10.0* Hct-30.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-15.2 Plt Ct-584*
[**2115-12-2**] 03:41AM BLOOD Neuts-86.9* Lymphs-6.8* Monos-5.1 Eos-1.1
Baso-0.1
[**2115-12-2**] 03:41AM BLOOD Plt Ct-469*
[**2115-11-22**] 12:04AM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2*
[**2115-12-2**] 03:41AM BLOOD Glucose-127* UreaN-17 Creat-0.6 Na-134
K-4.9 Cl-105 HCO3-19* AnGap-15
[**2115-11-28**] 05:00AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-130*
K-4.0 Cl-100 HCO3-21* AnGap-13
[**2115-11-22**] 12:04AM BLOOD Glucose-120* UreaN-15 Creat-0.6 Na-130*
K-4.3 Cl-96 HCO3-23 AnGap-15
[**2115-12-2**] 03:41AM BLOOD ALT-12 AST-24 LD(LDH)-219 AlkPhos-439*
Amylase-206* TotBili-0.3
[**2115-11-22**] 12:04AM BLOOD ALT-30 AST-28 AlkPhos-352* Amylase-140*
TotBili-0.5
[**2115-12-2**] 03:41AM BLOOD Albumin-2.2* Calcium-8.4 Phos-4.0 Mg-1.6
[**2115-11-22**] 12:04AM BLOOD Albumin-2.9* Calcium-8.0* Phos-3.6 Mg-2.2
Iron-16*
[**2115-11-29**] 10:48AM BLOOD Osmolal-278
[**2115-11-28**] 05:00AM BLOOD TSH-7.7*
[**2115-11-28**] 03:15PM BLOOD T4-7.3 T3-77* calcTBG-0.99 TUptake-1.01
T4Index-7.4
[**2115-11-29**] 12:45PM BLOOD Cortsol-34.6*
[**2115-12-2**] 04:09AM BLOOD Type-ART pO2-91 pCO2-30* pH-7.46*
calTCO2-22 Base XS-0
Brief Hospital Course:
This is a 69 year old female admitted from [**Hospital3 17921**]
Center in [**Location (un) 5450**] NH. The patient originally presented on
[**2115-11-9**] to [**Hospital3 17921**]
Center with severe back pain radiating to the right upper
quadrant and epigastric
area. She had associated nausea and vomiting. Ultrasound
revealed gallstones
and a thickened gallbladder wall with a dilated common bile duct
thought consistent with acute calculus cholecystitis. She was
started on cipro and flagyl on [**2115-11-9**], continued until
[**2115-11-17**]. On [**2115-11-11**] the patient underwent ERCP with reported
successful sphinterotomy and removal of diminutive stone
material. Patient's course was then complicated by an increasing
white count and fever. Abdominal CT revealed a large
retroperitoneal fluid collection. Placement of two
retroperitoneal drains on [**11-16**] and [**11-22**] were done.
[**2115-11-22**] - [**2115-11-30**] Patient continued to be febrile with nausea
and vomiting. Nasogastric tube inserted and left in for
decompression. Patient pancultured several times. Infectious
disease (ID) consulted. Intravenous antibiotics continued per
ID's recommendations. Patient experienced loose stool, cultures
sent for c. difficile. Patient became hyponatremic; thyroid
studies done showing a high thyroid stimulating hormone.
Endocrine consulted. [**2115-11-25**] CT of abdomen repeated showing a
decrease in the fluid collection. Nasogastric tube discontinued
on [**2115-11-29**]. Specimen obtained from drains and grew [**Female First Name (un) 564**],
MRSA and coag - staph. Patient was able to get out of bed and
ambulate.
Admitted to SICU:
On [**2115-12-1**] Patient became tachycardic with oxygen desaturation
to the 80's. Readmitted to SICU for respiratory distress and
intubated, then underwent CT Torso. This was negative for
pulmonary embolism. Chest xray did reveal enlarging effusions
and bilateral atelectasis with scattered opacities.
[**2115-12-2**] Drain of retroperitoneal fluid collection replaced.
[**2115-12-3**] Patient extubated and then reintubated for desaturations
and pulmonary edema.
[**2115-12-4**] Patient diuresised, [**12-4**] CXR: Interval improvement of
b/l pulmonary edema
On [**12-6**] patient had an abdominal CT - IMPRESSION: Improved
appearance of retroperitoneal fluid collections with
appropriately placed catheters. No new developing abscess.
Decreased but persistent pleural effusions and atelectasis.
[**2115-12-7**] Patient was extubated.
[**2115-12-8**] Patient reintubated with CXR revealing pulmonary edema
and bilateral pleural effusions.
[**2115-12-10**] Patient went back to the operating room for:
1. Incision and debridement of retroperitoneal abscess.
2. Tracheostomy tube placement.
[**2115-12-11**] - [**2115-12-15**]
Patient was weaned from ventilator to cpap.
Dobhoff tube placed for tube feedings.
CT of abd/pelvis on [**2115-12-15**] - Continued small fluid collection
interdigitating within the right retroperitoneum with
appropriately placed surgical and pigtail drainage catheters as
described. The collections are not significantly changed,
although they are slightly decreased in size when compared to
prior study. No new collections.
Enlarging pleural effusions and new biapical airspace disease,
likely developing pneumonia/aspiration.
[**2115-12-16**] L lung effusion drained for 900cc.
labetatol drip weaned to off.
[**2115-12-18**] Discontinued aztreonam and flagyl
[**2115-12-20**] WBC 10.1, all cultures negative.
Lasix drip being weaned.
Tube feeds at goal and tolerating well
Off ventilator, on trach collar mist with good oxygention.
[**2115-12-20**] - [**2115-12-24**]
Respiratory - Trach changed to PMV, good saturations with trach
mist.
Lasix changed to standing dose
Antibiotics changed to vancomycin and capsofungin
[**2115-12-23**] Patient went to CT, had retroperitoneal catheter
replaced with 12 french catheter with resulting drainage of 5cc
of purulent fluid. Catheter left in place.
[**12-24**] - CXR done - FINDINGS: Feeding tube is again seen with tip
off the film, past the second portion of the duodenum.
Tracheostomy tube is unchanged. Catheter in the right mid
abdomen is unchanged. The alveolar and interstitial infiltrates
are not significantly changed. There is a small left effusion
that is slightly larger than on the film from three days ago.
There continues to be retrocardiac opacity consistent with
volume loss/infiltrate/effusion.
[**2115-12-24**] - Patient transferred to floor.
[**2115-12-25**] - Discharge planning begun for rehab.
Physical therapy consult for chest PT and strengthening
Psych. consult - assessment and support
Consult to speech and swallow for evaluation and treatment.
L wrist ulcer from old IV site - healing, adaptik with dry
sterile dressing daily.
[**2115-12-27**] Family meeting with spouse, daughter, son, and Dr.
[**Last Name (STitle) **]. Plan discussed regarding further treatment and
course. Swallow study done. Started thin liquids. Out of bed to
chair. Continued physical therapy. Will get abd. CT on [**2115-12-31**]
and possible discharge to rehab. in one week.
[**Date range (1) 75676**]/08 Out of bed daily with physical therapy. Patient c/o
nausea, kub + stool throughout colon.
[**2115-12-31**] CT of Abd. -
IMPRESSION:
1. Persistent 4.2 x 2.5-cm rim-enhancing fluid collection in
the
retroperitoneum superior to the right kidney with pigtail
catheter that has
been partially retracted. Although the pigtail catheter lies at
the superior
portion of this lesion, re-manipulation may be helpful if the
catheter is not
draining. Please correlate clinically.
2. Improving bilateral pleural effusions and atelectasis.
Small pericardial
effusion.
3. Pneumobilia and air within the gallbladder. Please
correlate with any
recent manipulation.
[**2116-1-1**] - Pigtail drain discontinued.
[**2116-1-3**] - [**2116-1-12**] Patient continued to improve with complaints of
intermittent nausea. Bowel regimen began and medication
administration spaced out. Tube feedings weaned to just at night
and then discontinued. Patient placed on soft diet with calorie
counts and supplements. Patient also complained of trouble
sleeping, Psychiatry suggested Remeron at night for sleep. She
is now at 15mg and is sleeping better. On [**2116-1-10**] penrose drains
removed. Beta blockers weaned from 150mg tid to 50mg tid.
Current issues:
1. Surgical follow up - will return for abdominal CT and
appointment with Dr. [**Last Name (STitle) **] in [**3-3**] weeks.
2. Nausea/nutrition - will continue to encourage oral intake at
rehab. with the addition of high calorie supplements in between
meals.
3. Insomnia - Continue Remeron 15mg q HS.
4. Mobility - Will continue physical therapy at a more intense
level at [**Hospital1 **].
5. Antibiotics - As infectious disease recommended, we will
continue vancomycin and capsofungin until 2 weeks post
discontinuation of penrose drains. ([**2116-1-24**])
Medications on Admission:
Omeprazole 20 qd
prednisone eye drop
cosopt eye drops (both in left eye)
nystatin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
10. Caspofungin 70 mg Recon Soln Sig: Fifty (50) Recon Soln
Intravenous Q24H (every 24 hours): Discontinue on [**2116-1-24**].
11. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q24H (every 24 hours).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p biliary perforation from ERCP s/p placement of two
retroperitoneal drains
Retroperitoneal abscess complicated by respiratory failure.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Your follow up appointment with Dr. [**Last Name (STitle) **] is 1 pm Friday
Febuary 1st, [**Location (un) 10043**] [**Hospital Ward Name 23**] Building.
You are to have an abdominal CT on the [**Hospital Ward Name **] [**Hospital Ward Name 23**]
building, [**Location (un) **]. You are to arrive at 9:45m, your CT is
scheduled for 10:45. You must have nothing to eat 3 hours prior
to CT.
Completed by:[**2116-1-13**]
ICD9 Codes: 5119, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4698
} | Medical Text: Admission Date: [**2196-6-6**] Discharge Date: [**2196-6-15**]
Date of Birth: [**2109-11-12**] Sex: M
Service: NEUROSURGERY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
status post fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 86 year old male who was walking and fell off a 3ft
ledge, witnessed by family, no Loss of consiousness per family.
Patient was taken to an OSH and
transferred to [**Hospital1 18**] when head CT showed a very small occipital
ICH. On transfer, he was agitated and was intubated in the [**Hospital1 18**]
ER. Neurosurgery was consulted for further management.
Past Medical History:
CAD s/p CABG x4 in [**2176**]
Moderate aortic stenosis (1.0 cm2)
Marginal Cell Lymphoma (dx [**1-14**], asymptomatic, observing)
Hearing loss
PUD
Left eye loss now with prosthesis
S/P kidney stones
Inguinal hernia repair x 2
Spinal stenosis
Anxiety
S/P rotator cuff
BPH, s/p TURP, recurrent BPH
Social History:
He is married with two grown sons, lives with his wife who
is handicapped. No VNA services at home. Former worker at GE
then started his own contracting business, during which he had
known asbestos exposure. At baseline, high functioning and
physically active, walking and takse care of his sick wife. Does
not drive, has family members of grocery services bring food
home but able to take care of daily ADLs independently.
-Tobacco history: denied
-ETOH: denied
-Illicit drugs: denied
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
O: T: 99.4 BP: 147/91 HR: 78 R 16 O2Sats 96%
Gen: Intubated/ sedated. Facial lacerations, bilateral
periorbital ecchymosis. C-collar on.
Neuro:
Patient just intubated/ sedated. Per ER- prior to intubation
patient was moving all 4 ext purposefully.
Sedation held x 5-10 min.
No EO, BUE localizes to noxious, BLE withdraw briskly. Some
spont
mvmt of BLE noted. No commands. R pupil 3-2 mm, no left eye. +
[**Month/Year (2) **]/ gag.
On the day of discharge:
VS: T98.4, HR 66, BP 139/76, RR 20, 97% on RA
GEN: elderly male sitting in bed in NAD
HEENT: multiple healing scabs on face, L eye sewn shut
CV: RRR
PULM: mild rhonchi anteriorly throughout, improved with [**Month/Year (2) **]
ABD: soft, NT, ND
EXT: trace edema at ankles bilaterally
NEURO:
MS - when questions are written down for him, he is AAOx3. He
is very hard of hearing and so cannot understand spoken
questions. He follows simple commands, speech is fluent, no
dysarthria, comprehension is intact when instructions are
written or mimicked.
CN - L eye missing, R eye EOMI, R eye 3->2mm and brisk, face
symmetrical, facial sensation intact, tongue midline
MOTOR - MAEE, and when asked to do strength exam with written
instructions and mimicking he is at least 5-/5 troughout.
SENSORY - intact to LT throughout
COORDINATION - able to reach accurately bilaterally
GAIT - deferred
Pertinent Results:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2196-6-5**]
11:38 PM
IMPRESSION:
1. Endotracheal tube tip approximately 3.6 cm above the carina.
2. Calcified pleural plaques.
3. Engorged left upper lobe pulmonary vessels, which suggest
mild left sided heart failure.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2196-6-6**]
12:13 AM
IMPRESSION:
1. 12 x 6 mm left occipital parenchymal or subarachnoid
hemorrhage, unchanged compared to prior outside exam given
differences in technique.
2. Facial fractures, partially imaged, better seen on outside
hospital facial bone CT.
CT head [**2196-6-6**]
1. 13 x 8 mm left occipital hemorrhagic focus is most consistent
with
subarachnoid hemorrhage, less likely intraparenchymal
hemorrhage, and appears stable compared to the most recent prior
study of 10 hours prior.
2. Stable small subdural hematoma along the posterior left falx
cerebri.
3. Multiple facial fractures better assessed on the facial bone
CT from
outside hospital on [**2196-6-5**].
4. Stable osteolytic lesion in the left occipital bone unchanged
from MRI of [**2194-12-22**].
ECG [**2196-6-7**]
Sinus rhythm. Left bundle-branch block with a single narrow
complex beat.
Since the previous tracing left bundle-branch block has recurred
except for the one narrow beat. The rate is faster. Narrow beat
is after an atrial premature beat. Clinical correlation is
suggested.
CXR [**2196-6-7**]
As compared to the previous radiograph, the patient has been
extubated. The pre-existing post-surgical material after CABG
and the
pre-existing pleural calcifications are unchanged. There is no
evidence of
pneumothorax. Borderline size of the cardiac silhouette without
evidence of pulmonary edema. In the interval, the ventilation of
the lung appears to have slightly improved. No larger pleural
effusions. Moderate tortuosity of the thoracic aorta, no
evidence of chest wall lesions.
CXR [**2196-6-8**]
Pulmonary vascular congestion is improving. Borderline
cardiomegaly is
chronic. Multiple pleural calcifications should not be mistaken
for pulmonary abnormalities. No large scale atelectasis or
evidence of pneumonia. The patient has had median sternotomy and
coronary bypass grafting. No pneumothorax.
CXR [**2196-6-9**]
No acute cardiopulmonary process.
CXR [**2196-6-12**]
Compared to the prior exam, there has been a mild increase in
the
size of the heart with pulmonary vascular redistribution and
volume loss at both bases. Again seen are granulomas and
calcified pleural plaques,
sternotomy wires, and mediastinal clips.
IMPRESSION: Fluid overload.
[**2196-6-13**]
Improvment in pulmonary edema.
[**2196-6-13**] Video Swallow
No aspiration or penetration seen. For details and
recommendations, please refer to speech and swallow note in OMR.
[**2196-6-14**] Bilateral LENIs: negative
ADMISSION LABS:
[**2196-6-6**] 12:00AM BLOOD WBC-15.5*# RBC-4.33* Hgb-12.6* Hct-40.0
MCV-92 MCH-29.0 MCHC-31.5# RDW-14.0 Plt Ct-324
[**2196-6-6**] 12:00AM BLOOD Neuts-86.0* Lymphs-11.2* Monos-2.3
Eos-0.3 Baso-0.2
[**2196-6-6**] 12:00AM BLOOD PT-11.2 PTT-28.1 INR(PT)-1.0
[**2196-6-6**] 12:00AM BLOOD Glucose-157* UreaN-26* Creat-1.3* Na-132*
K-4.6 Cl-99 HCO3-21* AnGap-17
[**2196-6-6**] 12:00AM BLOOD ALT-15 AST-27 AlkPhos-74 TotBili-0.3
[**2196-6-6**] 12:00AM BLOOD Lipase-34
[**2196-6-6**] 12:00AM BLOOD cTropnT-<0.01
[**2196-6-6**] 12:00AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.1 Mg-1.6
[**2196-6-6**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-6-6**] 01:53AM BLOOD Type-ART Rates-/20 pO2-369* pCO2-33*
pH-7.45 calTCO2-24 Base XS-0 Intubat-INTUBATED
DISCHARGE LABS:
[**2196-6-14**] 04:55AM BLOOD WBC-10.2 RBC-3.66* Hgb-10.7* Hct-34.2*
MCV-93 MCH-29.2 MCHC-31.3 RDW-14.4 Plt Ct-301
[**2196-6-14**] 04:55AM BLOOD Glucose-137* UreaN-17 Creat-0.8 Na-140
K-3.0* Cl-104 HCO3-30 AnGap-9 (K was repleted after this result)
[**2196-6-14**] 04:55AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
Brief Hospital Course:
This is a 86 year old male who was walking and fell off a 3ft
ledge, witnessed by family the patient was transfered here from
an outside hospital on [**2196-6-6**]. Upon transfer, the patient was
aggitated and intubated in the [**Hospital1 18**] ED. A head Ct was
performed and consistent small occipital hemorhage and bilateral
Lefort 1 fracture.
Right medial orbital wall fx,Nasal fx with moderate deviation.
The patient was admitted to the TSICU.
In the morning of [**2196-6-6**], the patient continued to be
intubated and was weaned from sedation the ventilator was weaned
as tolerated. a NCHCT was performed and was found to be stable.
Plastic surgery consulted on the patient and recommended
conservative management which included:Unasyn and Dc on
Augmentin for a week total, Once extubated, limit diet to full
liquids and soft solids only to prevent lefort fragment
displacement,HOB elevation,Cool pack to face,Sinus precautions
once extubated, soft diet for 4 weeks when awake, Follow up in
[**Hospital **] clinic with chief on Friday. Plastic surgery reduced the
nasal fx at bedside and placed nasal packing to stay in place
for 48-72 hours.
[**6-7**], patient removed his nasal packing, has a nasal splint in
place. He remains stable on examination. C-spine was cleared. On
[**6-8**], he was transferred to the floor.
On [**6-9**], patient was febrile to 102, cultures were sent and a CXR
was ordered. On [**6-9**] started Cipro for UTI, which he completed on
[**6-15**]. The medicine service started following this patient. They
recommended following his lab work and a speech and swallow exam
Serial chest X-rays showed fluid overload and he was diareses
with Lasix. This improved on [**6-13**].
On [**6-12**] he was re-evaluated by medicine for delirium, this
improved on [**6-13**] and he passed his video swallow. He was on sinus
precautions and a soft diet for his facial fractures.
On [**6-14**] he was c/o leg pain, so he had bilateral LENIs which were
negative. He was then able to be safely sent to rehab.
Medications on Admission:
Flonase 50mcg 2 sprays per nostril daily
Aricept 5mg QHS
Vit D [**2184**] units daily
Colace 100mg [**Hospital1 **]
Flomax 0.4mg daily
ASA 81mg daily
Celexa 10mg daily
Ferrous Sulfate 325mg daily
MVI
Prilosec 20mg [**Hospital1 **]
Zocor 40mg daily
Vit B12 250 mcg daily
Proscar 5mg QHS
Discharge Medications:
1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Vitamin D3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever/HA.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Cipro I.V. 200 mg/20 mL Solution Sig: Four Hundred (400) mg
Intravenous Once for 1 doses: Last dose to complete course
should be on [**6-15**] at 4pm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
left occipital IPH
R medial orbital wall fracture
Nasal bone fracture
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
You are to be on a soft diet due to facial fractures for one
month from your accident. Also maintain sinus precautions: no
nose blowing, no straws.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You may have Heparin SC and Aspirin.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
SINUS PRECAUTIONS: NO STRAWS, NO NOSE BLOWING, ELEVATE HEAD OF
BED WHEN POSSIBLE
We made the following changes to your medications:
1) We STOPPED your FLONASE because of your nasal fractures.
2) We STARTED you on SUBCUTANEOUS HEPARIN three times a day.
You will only need this medication while you are at rehab.
3) We STARTED you on TYLENOL 325-650mg every 4 hours as needed
for pain.
4) We STARTED you on IV CIPRO. Your last dose will be [**6-15**] at
4pm.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in four weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Follow up in [**Hospital **] clinic with chief on Friday [**2196-6-17**] at
10:00am.
Please contact Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 6331**] reagarding appt location
as they need to ensure appropriate assistance is available for
the patient.
ICD9 Codes: 5990, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4699
} | Medical Text: Admission Date: [**2110-8-29**] Dictation Date: [**2110-9-25**]
Date of Birth: [**2110-8-29**] Sex: M
Service: NEONATOLOGY
This is an interim dictation covering the period from birth to
[**2110-9-25**].
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 56934**] is the former
1.41 kg product of a 33-2/7 weeks gestation pregnancy born to
a 32-year-old G1 P0 woman. Prenatal screens: Blood type B
positive, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, group B Strep
status unknown. The pregnancy was complicated by pregnancy-
induced hypertension. The mother presented on the day prior
to delivery with increasing symptoms of evolving preeclampsia
manifested by headaches and visual changes. Fetal ultrasound
showed poor fetal growth. She was admitted to [**Hospital1 **] on [**2110-8-26**]. Estimated fetal weight was less
than the third percentile and low amniotic fluid was noted.
Elective induction of labor was undertaken, but the mother
was taken to cesarean section due to intolerance of labor.
The infant emerged with good tone and cry. Apgars were 8 at
1 minute and 8 at 5 minutes. He was admitted to the Neonatal
Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.41 kg, 10th percentile. Length 40 cm, 10th
percentile. Head circumference 30.5 cm, 25th-50th
percentile. General: Nondysmorphic preterm male, good
activity and tone. Skin: Pink, no rashes. Head, eyes,
ears, nose, and throat: Anterior fontanel is soft and flat.
Positive red reflex bilaterally. Palate intact. Neck is
supple without masses. Chest: No grunting, flaring, and
retracting. Breath sounds clear and equal. Cardiovascular:
Regular rate and rhythm without murmur. Normal S1, S2.
Femoral pulses plus 2. Abdomen: Three-vessel cord, no
masses, no hepatosplenomegaly, positive bowel sounds. GU:
Preterm male, normal phallus. Testes descending. Anus:
Patent. Spine: Straight, normal sacrum. Hips: Stable.
Positive grasp. Positive morrow. Symmetric tone.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: Respiratory: [**Known lastname **] was in room air for his entire
Neonatal Intensive Care Unit admission. He did not have any
episodes of spontaneous apnea or bradycardia until [**2110-9-20**]
when he underwent a car seat test and had an episode of apnea
and bradycardia. He was observed for an additional five days
without any further episodes.
Cardiovascular: [**Known lastname **] has remained normotensive with normal
heart rates. A soft intermittent murmur was heard on day of
life number 25. A chest x-ray, four limb blood pressures,
and EKG were obtained with all results within normal limits.
He passed an oxygen challenge test. At the time of
dictation, the murmur was thought to be benign in nature.
Fluid, electrolytes, and nutrition: [**Known lastname **] was initially
nothing by mouth and started on intravenous fluids. He had
intermittent episodes of hypoglycemia during the first week
of life, which resolved with feedings and intravenous fluids.
Enteral feeds were started on day of life number one and
advanced to full volume. At the time of dictation, he is
breast feeding or bottle feeding expressed breast milk
fortified to 26 calories/ounce 4 calories by NeoSure powder
and 2 calories by corn oil. Weight on the day of dictation
is 2.195 kg, which is 4 pounds 13 ounces. Head
circumference is 32 cm and length is 44 cm.
Infectious disease: There were no infectious disease issues.
Gastrointestinal: [**Known lastname **] required treatment for unconjugated
hyperbilirubinemia with phototherapy. Peak serum bilirubin
occurred on day of life two, total of 7.89 mg/dl/0.5 mg/dl.
He received approximately six days of phototherapy. Rebound
bilirubin on day of life eight was a total of 2.6 mg/dl/0.5
mg/dl.
Hematological: Hematocrit was checked on day of life number
six and was 53 percent. [**Known lastname **] did not receive any
transfusions of blood products. He is being treated with
supplemental iron.
Neurology: [**Known lastname **] has maintained a normal neurological
examination during admission. There are no neurological
concerns at the time of discharge.
Sensory: Audiology: Hearing screening was performed with
automated auditory brain stem responses. [**Known lastname **] passed in
both ears.
Ophthalmology: Eyes were most recently examined on
[**2110-9-22**]. Retinas were found to be immature to zone three
with a recommended followup in three weeks. Appointment has
been scheduled with Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **] for [**2110-10-23**] at
9 a.m.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56935**], M.D., [**Street Address(2) 56936**], [**Location (un) **], [**Numeric Identifier 56937**]. Phone number is ([**Telephone/Fax (1) 56938**].
Fax number is ([**Telephone/Fax (1) 56939**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
FEEDING: Breast feeding or bottle feeding expressed mother's
milk fortified to 26 calories/ounce 4 calories by NeoSure
powder and 2 calories by corn oil. The NeoSure powder is
recommended until 6-9 months corrected age.
MEDICATIONS: Ferrous sulfate 25 mg/mL dilution 0.2 mL by
mouth once daily.
Vi-Daylin 1 mL by mouth once daily.
CAR SEAT POSITION SCREENING: As previously mentioned. The
initial car seat screening performed on [**2110-9-20**] had [**Known lastname **]
failing. A repeat was performed on [**2110-9-24**], and [**Known lastname **]
was observed for 90 minutes in his car seat without any
episodes of oxygen desaturation or bradycardia.
STATE NEWBORN SCREENS: Sent on [**9-2**] and [**2110-9-13**] with no
notification of abnormal results to date.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was administered
on [**2110-9-20**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of three of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED: Appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56935**] within three days of discharge.
Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **], Pediatric ophthalmologist for [**2110-10-23**] at
9 a.m. Phone number is ([**Telephone/Fax (1) 56940**].
DISCHARGE DIAGNOSES: Prematurity at 33-2/7 weeks gestation.
Intrauterine growth restriction.
Unconjugated hyperbilirubinemia .
Apnea of prematurity.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 43348**]
MEDQUIST36
D: [**2110-9-25**] 02:53:58
T: [**2110-9-25**] 04:21:04
Job#: [**Job Number 56941**]
ICD9 Codes: 7742, V053 |
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