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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4700
} | Medical Text: Admission Date: [**2132-12-12**] Discharge Date: [**2132-12-18**]
Date of Birth: [**2051-9-27**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Ambien
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
81 y old male w/ extensive history CAD s/p AMI at age 37, CABG
in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in [**2121**] (occuded
LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2), DES to OM1 for
NSTEMI in '[**29**], CHF with EF of 20% s/p cardiac resynchronization
and biV ICD, and [**11-20**] admission for SOB and chest tightness in
which he had an echo w/ severe AS with an area of <8 cm2, and
therefore underwent apico-aortic valve conduit placement on
[**2132-12-2**]. Pre-op he had a cath demonstrating patent RIMA -->
LAD, and SVG --> OM2, but occluded SVG --> PDA, but had no
intervention and no bump in enzymes. Post operatively he was
initially on Amiodarone for ventricular ectopy which resolved
after a few days. He had persistent hypotension and it took
several days to wean him off inotropic support. Coumadin was
started for afib and continued. He was discharged post-operative
day seven. His discharge VSS were 96/50, 95%, and HR of 71. He
was d/c'd on [**12-9**] with coumadin and lasix with an eye toward
restarting an ACE inhibitor if his blood pressure improved.
Today pt presented to [**Hospital3 24768**] with shortness of
breath. His BNP was found to be 1152 and CXR showed CHF. He was
given lasix 40 IV x 2 with good urine output. However, his BP
decreased to 76/40 and then increased to 86/60 at time of
transfer to [**Hospital1 18**] for further eal and treatment.
.
Upon presentation to [**Hospital1 18**] hs vitals were BP 85/43, HR 77, RR
18, 96% on 2L, T 97.1. He reported shortness of breath that
improved with lasix. He reports that the shortness of breath
began this morning gradually. No chest pain. He is not walking
around much so he denies dyspnea on exertion. He denies PND, but
reports orthopnea. He does not know if his leg swelling is
increasing or decreasing. He does not know if he has had weight
gain or weight loss. He denied lightheadedness, cough, fevers,
chills.
Past Medical History:
# CAD
- s/p AMI at age 37
- s/p CABG in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in
[**2121**] (occuded LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2)
- s/p DES to OM1 for NSTEMI in '[**29**]
- [**11-24**] cath demonstrating patent RIMA --> LAD, and SVG --> OM2,
but occluded SVG --> PDA
# CHF with EF of 25% s/p cardiac resynchronization and biV ICD
# Severe AS with an area of <8 cm2 s/p apico-aortic valve
conduit placement on [**2132-12-2**]
- conduit gradient post-procedure: peak 5, mean 2.4 mm Hg
- native Aortic valve with a peak gradient 23 mm Hg
# Chronic Systolic Congestive Heart Failure with EF 20%
# Biventricular ICD and Cardiac Resynchronization
# Hypertension
# Hyperlipidemia
# History of Abscess Excision
# Cholecystectomy
# History of Remote MVA
Cardiac Risk Factors: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
Social History:
The patient lives alone in [**Location (un) 11790**]. Social history is
significant for the absence of current tobacco use though the
patient has a remote smoking history. He reports smoking 1PPD
for 20 years, but quit at age 37. There is no history of alcohol
abuse but he drinks alcohol occasionally. There is no family
history of premature coronary artery disease or sudden death.
Family History:
No premature coronary artery disease
Physical Exam:
VS - BP 81/42 , HR 66, RR 25, 96% on 2L, T 98.0
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: arcus senilis. sclera anicteric. PERRL, EOMI.
Neck: JVP ~12
CV: Irregularly irregular. III/VI systolic murmur at apex. No
thrills, lifts. No S3 or S4.
Chest: tachypneic, speaking in complete sentences, crackles
bilaterally 1/3rd up
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace edema. stiches in L femoral groin, pulses intact
femoral area
Skin: warm
Pulses:
Right: Femoral 2+ DP 1+ PT 1+
Left:Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**2132-12-12**] 09:15PM PT-18.8* PTT-30.5 INR(PT)-1.8*
[**2132-12-12**] 09:15PM PLT COUNT-386#
[**2132-12-12**] 09:15PM WBC-9.7 RBC-3.26* HGB-9.6* HCT-30.5* MCV-93
MCH-29.5 MCHC-31.6 RDW-15.3
[**2132-12-12**] 09:15PM CALCIUM-8.1* PHOSPHATE-4.2 MAGNESIUM-2.3
[**2132-12-12**] 09:15PM CK-MB-NotDone cTropnT-0.35*
[**2132-12-12**] 09:15PM CK(CPK)-20*
[**2132-12-12**] 09:15PM GLUCOSE-145* UREA N-26* CREAT-1.1 SODIUM-133
POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-37* ANION GAP-10
Brief Hospital Course:
81 y old male w/ extensive history CAD s/p AMI at age 37, CABG
in [**2115**] (LIMA-LAD, SVG-PDA, SVG-OM1) with redo in [**2121**] (occuded
LIMA-LAD and SVG-PDA, RIMA-LAD,SVG-PDA, SVG-OM2), DES to OM1 for
NSTEMI in '[**29**], CHF with EF of 20% s/p cardiac resynchronization
and biV ICD, and severe AS s/p apico-aortic valve conduit
placement on [**2132-12-2**] now presenting with SOB. Patient was
admitted to the floor team who initiated diuresis. Patient was
then noted to be transiently hypotensive and was transferred to
the CCU for management.
.
#Hypotension: On arrival in CCU, patient noted to be hypotensive
in upper extremity b/l, but with elevated SBP in lower
extremity. Impression was for either b/l subclavian stenosis or
normal physiology with his apical-aortic conduit that was
preferentially directing flow to the lower extremity. Patient
was asymptomatic from the hypotension, and subsequent upper
extremity BP's were regularly in normal range.
.
#SOB: In CCU, patient was persistently tachypneic 20-30's at
baseline. Exam was consistent with volume overload with
elevated JVP, peripheral edema, and crackles on lung exam.
Diuresis resulted in mildly improved respiratory function.
Patient was optimized from a volume perspective, but continued
to be tachypneic with exertion. Patient was afebrile, without
WBC count elevation, and impression was for post-operative
deconditioning. He was transferred to the floor for management
where he was evaluated by PT and recommended for inpatient rehab
on discharge.
.
#Atrial Fibrillation: Patient was rate controlled with HR in
60's during much of his hospital stay. Coumadin was restarted
for anticoagulation. Please have your INR checked regularly on
discharge to ensure therapeutic level of your coumadin.
.
#Mental Status: Patient had episode of altered mental status on
AM of [**2132-12-16**]. Neuro exam was non-focal, CT head negative,
Neuro consult recommended A1c and lipid panel. Impression was
for benzo intoxication as patient had received an additional
dose of xanax on the AM of this episode. also w/ component of
sleep deprivation. Recommend that patient discontinue xanax on
discharge.
.
#PT: Physical therapy evaluated patient and recommended acute
[**Hospital 19586**] rehab on discharge.
.
#CAD: Patient was started/continued on ASA, zetia, low dose
beta-blocker, captopril, and statin therapy. Recommend
outpatient f/u with Cardiology.
.
Remainder of the [**Hospital 228**] hospital course was uncomplicated.
Medications on Admission:
On admit to CCU
Docusate [**Hospital1 **]
Ezeteimibe 10 q day
Aspirin 81 q day
Potassium chloride 20 [**Hospital1 **]
Toprol XL 25 q day
Pantoprazole 40 q day
Lasix 20 mg [**Hospital1 **]
Coumadin 1 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Watch [**Doctor Last Name **] Manor
Discharge Diagnosis:
CHF Exacerbation
.
Apical-aortic conduit
Atrial Fibrillation
Coronary Artery Disease
Discharge Condition:
Stable, to acute rehab to address oxygenation.
Discharge Instructions:
you were admitted to the hospital for evaluation of shortness of
breath. Your symptoms are likely related to your congestive
heart failure. While in the hospital you were diuresed (fluid
was removed). Please continue to take all medications as
directed upon leaving the hospital. Some continued shortness of
breath is to be expected after your recent surgery and extended
hospital stay. Please continue to work with physial therapy in
this regard. Should you develop any worsening of your symptoms,
however, or if you feel that you have any new symptoms that are
concerning to you such as chest pain, productive cough, or any
other worrisome complaints please call your PCP or return to the
Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1-1.5 liters per day.
Followup Instructions:
Please call your PCP/Cardiologist Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**]
([**Telephone/Fax (1) 24721**] for an appointment in the next 2-3 weeks. Family
assures they will call for a follow-up appointment.
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], your
cardiologist, on [**12-24**] at 4:40pm. Please report to the [**Hospital Ward Name 23**]
Clinical Center at [**Location (un) **]., [**Location (un) 436**].
Please have your INR level checked regularly upon leaving the
hospital to ensure a therapeutic level of your coumadin (INR
[**3-15**]).
ICD9 Codes: 5180, 4280, 4019, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4701
} | Medical Text: Admission Date: [**2141-3-8**] Discharge Date: [**2141-3-14**]
Date of Birth: [**2102-8-22**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: A 38-year-old woman with a
history of hepatitis C, B cirrhosis, grade 3 esophageal
varices status post banding secondary to GI bleed,
insulin-dependent diabetes mellitus who was recently admitted
to [**Hospital1 69**] from [**2-27**] to
[**3-6**] after having an upper GI bleed and mental status
changes. The patient's workup from prior admission included
diagnostic and therapeutic paracenteses times two which were
both sterile. An esophagogastroduodenoscopy confirmed
placement of bands and more bands were placed. Treatment of
hepatic encephalopathy with lactulose with improvements in
mental status to baseline. Of note, during the last
admission the patient's mental status improved to baseline
from [**2-27**] to [**3-2**]. On [**3-6**] she became
confused again prompting a second paracentesis which was also
sterile. There was no evidence of GI bleed at that time.
The patient improved to baseline again after repeated doses
of lactulose and the patient was discharged on [**3-6**].
On [**3-7**] according to outside hospital reports and the
patient's husband, the patient had been in her normal state
of health, however, she felt slightly nauseated that evening
and fell asleep on the cough. In the morning she was very
difficult to arouse and EMS was called. The patient was
found to be awake but confused and combative and was brought
to [**Hospital3 **] Hospital where she was afebrile with normal vital
signs. She was subsequently transferred to [**Hospital1 346**] for further care.
PAST MEDICAL HISTORY:
1. Hepatitis C status post transfusion in [**2118**].
2. Grade 3 varices banded [**2141-2-14**].
3. Upper gastrointestinal bleed [**2141-2-13**], requiring
transfusion.
4. Ascites. No history of spontaneous bacterial
peritonitis.
5. Esophageal Candidiasis.
6. Urinary tract infection [**2141-2-13**].
7. History of repeated hepatic encephalopathy.
MEDICATIONS ON ADMISSION:
1. Insulin 70/80 15 units q. a.m.
2. Humalog sliding scale q. p.m.
3. Ultram one to two tabs p.o. q. 4-6h. p.r.n.
4. Nadolol 40 mg p.o. q. day.
5. Protonix 40 mg p.o. b.i.d.
6. Actigall 300 mg p.o. t.i.d.
7. Aldactone 100 mg p.o. q. day.
8. Lasix 80 mg p.o. q. day.
9. Carafate slurry 1 gram in 5 cc water q.i.d.
10. Glucotrol XL 10 mg p.o. q. day.
11. Ciprofloxacin 500 mg p.o. q. day.
12. Lactulose 30 mg p.o. t.i.d.
ALLERGIES: Erythromycin and Percocet.
SOCIAL HISTORY: The patient lives with her husband. Denies
alcohol, tobacco or drugs.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.1 degrees, blood pressure 100/50, rate 82, respiratory
rate 18, 98% on room air. Fingerstick 172. Generally, young
cachectic woman. Head, eyes, ears, nose and throat: No
icterus. Normocephalic, atraumatic. Pupils equal, round and
reactive to light. Extraocular movement but with a lazy left
eye. Neck was supple. No lymphadenopathy. Cardiovascular:
Regular rate and rhythm. No murmurs. Pulmonary: Decreased
breath sounds at bases. No crackles, wheezes or rubs.
Abdomen was protuberant with a thrill at the belly button.
Non-tender with positive distention and shifting dullness.
Extremities: 2+ bilateral lower extremity edema. Neuro:
The patient was perseverating. She was alert and oriented to
person, occasionally to place but inconsistently. Patient
was not aware of the date. Patient had mild asterixis.
Patient had normal strength and sensation.
LABS ON ADMISSION: White count 5.2 with 57 segs, 10 bands,
13 lymphs, 15 monos. Hematocrit 37, platelets 83, sodium
129, potassium 4.8, chloride 98, bicarb 23, BUN 47,
creatinine 1.3, glucose 193. AST 75, ALT 60, total bilirubin
3.8, alk phos 124, protein 5.4, albumin 3.5.
HOSPITAL COURSE: The patient was treated with lactulose p.o.
t.i.d. Her mental status gradually improved throughout the
first day of admission, however, the night of the first
admission patient vomited after dinner after taking her
lactulose and took another 15 mL of lactulose after vomiting.
The patient slept through the night. Denied any bowel
movements during the night and was found on the second day of
admission to be unresponsive to voice and minimally
responsive to painful stimuli. The patient was found to be
guaiac negative and there was no indication of bleeding. The
patient received multiple lactulose enemas. The patient's
vital signs were normal. The patient was protecting her
airway but, after multiple doses of lactulose throughout the
day, the patient was determined to need MICU level care for
closer nursing supervision. An NG tube was placed on the
floor and a diagnostic paracentesis was performed. Urine
cultures were sent. The ascites culture and labs were
negative for infection as was the urine culture. The patient
was admitted to the MICU where she was fluid resuscitated and
continued to receive lactulose. The patient mental status
cleared approximately 24 hours after the onset in the
hospital of her unresponsiveness. The patient was
transferred back to the floor where she, now with the benefit
of having a feeding tube in place, began tube feeds as well
as a p.o. diet and p.o. lactulose t.i.d. The patient's
mental status gradually cleared throughout the course of her
admission. The patient had a therapeutic paracentesis
performed on [**3-13**] yielding 4.7 liters of clear
straw-colored fluid which was not sent for analysis given
that the patient was currently at her baseline with no
suspicion of infection. The patient's NG tube was
repositioned under fluoroscopy to be post-pyloric to lower
risk of aspiration. The patient's blood sugars were elevated
throughout admission as her tube feed advanced to goal and
her insulin regimen was adjusted with recommendations from
the [**Last Name (un) **] Center consult service. The patient continued to
receive tube feeds in addition to p.o. diet. The patient was
started on Flagyl 250 mg t.i.d. as an additional treatment
for hepatic encephalopathy and it is anticipated this will be
continued at least for the foreseeable future and will be
reevaluated by the Liver service at a later time.
DISCHARGE STATUS: The patient is awaiting placement at rehab
versus a skilled nursing facility at this time.
DISCHARGE DIAGNOSES:
1. Hepatitis C.
2. Cirrhosis.
3. Ascites.
4. Grade 3 esophageal varices banded secondary to upper
gastrointestinal bleed.
5. Hepatic encephalopathy.
6. Insulin-dependent diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. day.
2. Aldactone 100 mg p.o. q. day.
3. Protonix 40 mg p.o. b.i.d.
4. Lactulose 30 mg p.o. t.i.d.
5. Carafate 1 gram slurry with 5 cc of water p.o. q.i.d.
6. Nadolol 40 mg p.o. q. day.
7. Flagyl 250 mg p.o. t.i.d.
8. NPH insulin 10 units q. a.m., 10 units q. p.m. with a
regular insulin sliding scale as follows starting with blood
sugars greater than 100 treat with 3 units of regular insulin
and advance by 2 units of insulin for every 50 point increase
in blood sugar up to a maximum of 15 units at blood sugars of
greater than 400.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 29946**]
MEDQUIST36
D: [**2141-3-14**] 15:43
T: [**2141-3-14**] 15:34
JOB#: [**Job Number 30547**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4702
} | Medical Text: Admission Date: [**2184-9-7**] Discharge Date: [**2184-9-7**]
Date of Birth: [**2114-1-25**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 111878**] is a 70M with a history of hep C cirrhosis
(c/b SBP, HE and Varices) who presented with bleeding esophageal
varices. Presented to LGH earlier today with 3 episodes of
hematemesis. GI there tried to band 4 varices but two popped
off. He also received clips to ulcerated tissue and 7cc of
sodium laurate. He received 4U PRBC, 2 FFP, 2 U PLTs with
persistent hypotension requiring norepinephrine 0.1. Patient was
started on PPI and octreotride drip, ceftriaxone, and intubated
prior to transfer. He also received vecuronium. During transport
given 2mg Versed. He received a total of 6 liters of fluid with
no urine ouput per report.
In the [**Hospital1 18**] ED, initial VS were: BP 93/53 (on norepi), 73, 100%
on CMV. Labs were notable for...
-K of 6.5 for which patient received calcium gluconate, insulin
and d50.
-pH of 7.17 with a lactate of 4.3.
-INR 2.0 with fibrinogen 104
-BUN/CR 64/2.9
-HCT 28
-WBC 20
-Plt 131
On arrival to the MICU, patient is intubated and sedated and
unable to provide further history. Initial VS are Temp 93.0 HR
87 BP 79/54 O2 100% on CMV
Review of systems:
patient is intubated and sedated
Past Medical History:
-hep C cirrhosis (c/b SBP, HE and Varices)
-other details unknown
Social History:
patient is intubated and sedated
Family History:
patient is intubated and sedated
Physical Exam:
Vitals: Temp 93.0 HR 87 BP 79/54 O2 100% on CMV
General: intubated, sedated, jaundiced
HEENT: Sclera icteric. Blood dripping from mouth around ET tube.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Coarse upper airway sounds
Abdomen: very distended, no response to palpation
GU: foley
Ext: cold extremities, 1+ pulses, 1+ pitting edema bilaterally
Neuro: pupils pinpoint. No response to pain.
Pertinent Results:
[**2184-9-7**] 12:52AM BLOOD WBC-20.0* RBC-3.27* Hgb-9.3* Hct-28.0*
MCV-86 MCH-28.5 MCHC-33.2 RDW-19.0* Plt Ct-131*
[**2184-9-7**] 02:50AM BLOOD WBC-23.3* RBC-3.25* Hgb-9.4* Hct-28.1*
MCV-87 MCH-29.0 MCHC-33.5 RDW-19.2* Plt Ct-140*
[**2184-9-7**] 12:52AM BLOOD PT-20.9* PTT-38.6* INR(PT)-2.0*
[**2184-9-7**] 12:52AM BLOOD Fibrino-104*
[**2184-9-7**] 02:50AM BLOOD Glucose-214* UreaN-70* Creat-3.0* Na-139
K-5.2* Cl-111* HCO3-18* AnGap-15
[**2184-9-7**] 02:50AM BLOOD ALT-32 AST-84* LD(LDH)-261* AlkPhos-44
TotBili-5.0*
[**2184-9-7**] 02:50AM BLOOD Albumin-2.6* Calcium-8.1* Phos-6.7*
Mg-1.8
[**2184-9-7**] 01:50AM BLOOD Type-ART Rates-14/ Tidal V-400 PEEP-5
FiO2-100 pO2-197* pCO2-52* pH-7.11* calTCO2-18* Base XS--13
AADO2-463 REQ O2-79 -ASSIST/CON Intubat-INTUBATED
[**2184-9-7**] 12:53AM BLOOD Glucose-125* Lactate-4.3* Na-136 K-6.5*
Cl-115* calHCO3-14*
[**2184-9-7**] 02:58AM BLOOD freeCa-1.04*
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Mr. [**Known firstname **] [**Known lastname 111878**] is a 70 year old male with a history of hep C
cirrhosis (complicated by SBP, Hepatic Encephalopathy, and
Varices) on home hospice who presented to LGH with bleeding
esophageal varices and was intubated for an uppper endoscopy. He
was transferred to [**Hospital1 18**] for further management and the patient
was extubated and passed away as consistent with his previously
stated wishes.
ACTIVE ISSUES:
#) Variceal Bleed/Hemorrhagic Shock: The patient was initially
admitted to LGH with hematemesis. He was emergently intubated
for airway protection in the acute setting although his daughter
later reported this was not consistent with his wishes. He
underwent a complex EGD intervention involving 5 bands, clips to
ulcerated tissue and 7cc of sodium laurate. He received multiple
units of blood, platelets, and coagulation factors but still had
persistent hypotension, lactic acidosis and oliguric renal
failure. After transfer to [**Hospital1 18**] he was admitted to the medical
ICU.
A family meeting was held at the bedside with the MICU team and
the patient??????s daughter (HCP) [**Name (NI) **]. She described the
patient??????s recent course including multiple hospitalizations from
cirrhosis resulting in the patient losing his independence. He
had recently moved from his home in [**State 531**] to [**Location (un) 86**] to be
taken care of by his daughter and grandchildren. He has been on
home hospice. [**Doctor Last Name **] describes the patient as feeling that he
was going to be passing away soon and was ready. He saw a priest
yesterday for that purpose. [**Doctor Last Name **] stated that he definitely
did not want to be intubated, but she felt pressure in the ED to
agree to it. She said that he would definitely want the tube
removed now. She voiced understanding that this would result in
his passing away. He was then extubated and passed away
peacefully shortly thereafter with family at the bedside. Time
of death was 4:50 AM on [**2184-9-7**]. Cause of death was hemorrhagic
shock from variceal bleeding from hepatitis C cirrhosis. Autopsy
was declined by the family.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH
records.
1. Ciprofloxacin HCl 750 mg PO 1X/WEEK (MO)
2. Vitamin D Dose is Unknown PO Frequency is Unknown
3. Lactulose 20 mL PO BID
4. Rifaximin 550 mg PO BID
5. Nadolol 20 mg PO DAILY
6. sitaGLIPtin *NF* 50 mg Oral daily
7. Montelukast Sodium Dose is Unknown PO Frequency is Unknown
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 5715, 5849, 2762, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4703
} | Medical Text: Admission Date: [**2189-3-13**] Discharge Date: [**2189-6-16**]
Date of Birth: [**2189-3-13**] Sex: F
Service:
HISTORY: [**Known lastname 636**] is a 28 and 0/7 week twin with a birth weight
of 719 grams who was admitted to the NICU for prematurity at
28 weeks, respiratory distress syndrome, sepsis evaluation,
patent ductus arteriosus treated with Indocin.
MATERNAL HISTORY: She was born as Twin A to a 33-year-old
G1, P0 now 2 mother whose prenatal screens were as follows.
Hepatitis B surface antigen negative. RPR nonreactive.
Rubella immune. Maternal blood type was AB+, antibody
negative. Estimated date of delivery was [**2189-6-5**].
Prenatal course was significant for IVS, dichorionic,
diamniotic twins, incompetent maternal cervix, preterm labor
with rupture of membranes of Twin A. IUGR of Twin A. GBS was
negative. The twins delivered via cesarean section secondary to
unstoppable
preterm labor. Mom did not have any fevers during delivery.
[**Known lastname 636**] emerged active with intermittent apnea. She received
positive pressure ventilation and was intubated in the
delivery room. Apgar's were 6, 7.
Upon admission to the NICU [**Known lastname 636**] was noted to be 719 grams,
less than 10th percentile. Length was 31.5 cm, less than 10th
percentile. Head circumference 25.25 cm, 20 to 50th
percentile. Her initial oxygen saturation was 94%. Her blood
pressures were 69/20 with a mean of 39. She was active. She
had moderate aeration bilaterally. Tone was appropriate for
age. Anus is patent. Normal female genitalia appropriate for
age. Initial D. Stick was 46.
HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname 636**] received 2
doses of Surfactant. She was intubated with maximum
pressure settings of 23/6. She was intubated from day of life
1 until day of life 32 from [**3-13**] to [**2189-4-14**]. She
was extubated to CPAP and remained on CPAP for one week from
[**4-15**] to [**2189-4-22**]. She remained on oxygen until [**2189-5-17**], day of life 65. She was started on Caffeine at 11
days of age and continued until day of life 55. At discharge
she had no apneic episodes.
Cardiovascular: She was noted to have a PDA and was treated
with 2 courses of Indocin on day of life 3 to 4. [**2189-3-18**] echo confirmed that the PDA had closed.
FEN/GI: She started enteral feeds on day of life 8, completed
and tolerated full feeds by day of life 14 at which time she
was taken off parenteral nutrition. She was advanced up to 30
K cals per ounce of breast milk and was weaned back down to
breast milk 26 K cals made up with [**Year (4 digits) 66210**] or Neosure which
will be her discharge feeding regimen. Her discharge weight
was 3230 grams. Her max bilirubin was 6.0. she remained on
phototherapy from day 1 to day of life 12.
Heme: Her most recent crit was on [**2189-5-12**] which was 31
with a reticulocyte count of 7. She was transfused on
[**2189-3-15**], [**2189-3-20**] and [**2189-4-6**].
She has been receiving iron and multivitamins in the hospital
and will be discharged home on those as well.
Infectious disease. She received a 7 day course of
antibiotics, all cultures were negative. CSF cultures were
negative as well.
Neurology: Day of life 4 head ultrasound showed bilateral
IVH, left grade 2 to 3, right Grade 1 to 2. Day of life 7
head ultrasound showed increasing size of the ventricles but
day of life 21 the ventricles had decreased in size when the
clot was evolving. Day of life 30 head ultrasound continued
to show resolving clot and by day of life 60 head ultrasound
had normalized. The ventricles continued to be at the upper
limits of normal in size. Patient was seen by Neurology Service
from [**Hospital1 **]. They found her exam to be normal and suggested
outpatient follow-up in2 months with the potential for further
imaging such as an MRI during early childhood.
Sensory: Audiology: Hearing screen was performed with
automated auditory brain stem responses in the past.
Ophthalmology: Eyes were examined most recently on [**2189-6-8**] revealing ROP on the left Stage 1, zone 3. Right side
was mature. Recommended follow-up in 3 weeks during the week
of [**2189-6-28**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
Primary pediatrician will be [**First Name5 (NamePattern1) 487**] [**Last Name (NamePattern1) 66211**] through
[**Location (un) 17566**], [**Telephone/Fax (1) 37911**].
CARE/RECOMMENDATIONS: Feeds at discharge: Recommended feeds
will be breast milk or [**Telephone/Fax (1) 66210**] 26 until [**Known lastname 636**] demonstrates
continued weight gain at which time breast milk can be weaned
to 24 K cals, continued to be made up with [**Known lastname 66210**]. Her
brother [**Name (NI) 1661**] remains on [**Name (NI) 37112**] 24, breast milk 24. It was
offered and possible for mom to switch [**Name (NI) 1661**] over to
[**Name (NI) 66210**] as well.
While she remains on [**Name (NI) 66210**] it is recommended that she
remain on that formula until 6 to 9 months corrected age.
MEDICATIONS:
1. Iron
2. Multivitamins.
Car seat position screening she passed. State newborn
screening status: Was on [**2189-3-28**].
IMMUNIZATIONS: She received Pediarex on [**2189-5-12**], HIB
on [**2189-5-13**] and PCV on [**2189-5-13**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the following.
Daycare during RSV season, smoker in the household,
neuromuscular disease, airway abnormalities or school age
sibling. Or with chronic lung disease.
3. 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 Childs
life immunization against influenza is recommended for
household contacts and out of home care givers.
FOLLOW UP:
1. Neonatal [**Hospital 878**] clinic 8 weeks after discharge in [**8-9**]. Infant [**Hospital 702**] clinic
3. Early intervention.
Pediatrician within one to two days after discharge.
5. Ophthalmology during the week of [**2189-6-28**].
Conatct information has been given to parents who will scedule
this appoitnment
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
MEDQUIST36
D: [**2189-6-17**] 09:17:56
T: [**2189-6-17**] 11:14:03
Job#: [**Job Number 66212**]
ICD9 Codes: 769, 7742, 2761, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4704
} | Medical Text: Admission Date: [**2183-8-31**] Discharge Date: [**2183-9-15**]
Date of Birth: [**2121-8-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yo female with history of hypothyroidism and chronic back
pain s/p multiple back surgeries wuth epidural steroid injection
2 months prior to admission who presented to OSH with fever for
5 days, found to have pancreatitis and multifocal pneumonia,
transferred to [**Hospital1 18**] for ERCP.
On admission at OSH [**8-28**], she was found to have elevated lipase
(peak 1690, down to 613 on transfer), elevated LFTs (admission
AST 130/ALT 143/Alk phos 179, transfer AST 43/ALT 67/Alk phos
113/T bili 0.5), and MRI findings consistent with acute
pancreatitis. MRCP showed no fluid collection, pseudocyst,
abscess, biliary duct dilation, nor pancreatic duct dilation.
Patient was initially managed with IVF. She became increasingly
short of breath on [**8-29**] however, saturating 90% on 4L O2, and
was transferred to the OSH ICU. CXR showed bilateral patchy
infiltates concerning for biliary sepsis. CT Chest showed
extensive consolidation with air bronchograms in RUL and ground
glass opacities in LUL as well as small bilateral pleural
effusions. CT pelvis negative for abscess. She was started on
antibiotics (vanc, zosyn, moxifloxacin) and cultures were sent
(pending). She is being transferred to [**Hospital1 **] for ERCP on Tuesday.
.
In the [**Hospital Unit Name 153**], she is afebrile and pain-free.
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:
Hypothyroidism
Chronic back pain s/p multiple surgeries and epidural steroid
shots
Social History:
From [**Location (un) 6185**], came to [**Location (un) 86**] to visit children.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Negative for malignancy, daughter has polymyositis
Physical Exam:
General: Alert, oriented, no acute distress, afebrile
HEENT: Sclera anicteric, oropharynx clear
Neck: supple,
Lungs: diffuse bilateral rhonchi posteriorly throughout lung
fields as well as anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, 1+ non pitting edema
Pertinent Results:
OSH Labs:
lipase: peak 1690, down to 613 on transfer
LFTs: admission AST 130/ALT 143/Alk phos 179, transfer AST
43/ALT 67/Alk phos 113/T bili 0.5 LDH: 244 lactate: 1.3
WBC: 12.8
TG: 241
TSH 0.38 free T 4 1.8
Blood cx pending
UA negative
MRI/MRCP: Findings suggest mild evolving acute pancreatitis,
without organizing or drainable fluid collection, pseudocyst or
abscess. No evidence for pancreatic hemorrhage or necrosis.
Small right and tiny left pleural effusions are documented.
Admission Labs:[**2183-9-1**] 04:44AM WBC-8.5 RBC-3.35* Hgb-9.5*
Hct-28.8* MCV-86 Plt Ct-268
[**2183-8-31**] 09:06PM Glucose-103* UreaN-5* Cr-0.8 Na-143 K-4.3
Cl-109* HCO3-22
[**2183-8-31**] 09:06PM ALT-48* AST-48* AlkPhos-99 TotBili-0.5
[**2183-9-1**] 04:44AM proBNP-[**Numeric Identifier 88471**]*
[**2183-8-31**] 09:06PM Albumin-2.9* Calcium-8.3* Phos-2.0* Mg-2.1
[**2183-9-4**] Chest CT:CT CHEST
REASON FOR EXAM: Characterize diffuse opacities described in
prior chest
x-ray from [**8-31**] and [**9-1**].
TECHNIQUE: Multidetector CT through the chest was acquired
without IV
contrast. 5-, 1.25-mm collimation images, sagittal and coronal
reformations were provided and reviewed.
FINDINGS: The airways are patent to the segmental level. There
is increase in number and size of mediastinal lymph nodes
located in all stations. They measure up to 8 mm in the
prevascular station, 10 mm in the upper pretracheal station, in
the left lower paratracheal station measuring 10 mm, precarinal
station up to 12 mm. Evaluation of hilar lymph nodes is limited
due to the lack of IV contrast. Some of the lymph nodes are
calcified in the left hilum and the left paraesophageal station.
There is mild cardiomegaly. There is no pericardial effusion.
Mild-to-moderate calcifications are in the LAD and circumflex
coronary arteries. Cardiac size is normal.
Large right and moderate left pleural effusions are layering and
nonhemorrhagic, associated with adjacent areas of atelectasis. A
noncalcified lung nodule in the right lower lobe measures 5 mm
(4, 105). Large multiple areas of ground glass opacity
associated with smooth interlobular septal thickening are
present in the upper lobes bilaterally, right greater than left.
The upper abdomen is unremarkable. There are no bone findings of
malignancy
IMPRESSION: Improved pulmonary edema. Bilateral pleural
effusions.
5-mm right lower lobe lung nodule. Followup in one year is
recommended.
Cardiomegaly.
Brief Hospital Course:
1) Acute renal failure: Developed after transfer from OSH,
likely ATN secondary to contrast load on [**2183-8-30**] + SIRS +
hypotension in the ICU overnight the evening of [**2183-8-31**]. FENa
5%, lytes remained stable. Patient was given continuous IV
fluids and developed post-ATN diuresis complicated by one
episode of hypernatremia. Her creatinine slowly improved and was
1.5 at the time of discharge.
.
2) ?Multifocal pneumonia: Could very well have represented ARDS,
but given fevers, persistent oxygen requirement and concerning
CT at OSH patient was treated with Vanc/Zosyn. Blood cultures
were sent at the OSH and remained negative. Patient was weaned
off of oxygen and remained stable on room air.
.
3) Pancreatitis: Lipase significantly decreased by the time of
transfer; patient was never nauseous or with abdominal pain.
ERCP was not felt to be indicated and she was followed
clinically as her diet was advanced. A repeat MRCP performed on
[**2183-9-11**] was normal.
.
4) Intermittent fevers: Patient had continued low-grade fevers
throughout her hospital stay. CXR, UA, blood cultures, and MRCP
were unrevealing. Infectious disease was consulted and
suggested that a drug reaction to penicillin be considered as
part of the differential diagnosis, but also recommended Hep C,
Hep B, RPR, and HIV as initial work up. These were obtained and
returned negative prior to the patient's discharge except for
the Hepatitis C serologies which are still pending. As the
workup was in progress, the patient's fever curve decreased and
she subsequently became afebrile 3 days prior to her discharge.
Because the patient deffervesced, the infectious disease service
did not feel that an echocardiogram, blood smears for parasites,
or other serologies needed to be pursued as an inpatient. The
service made two other recommendations:
A) a shorter follow up interval for her small lung nodule than
12 months due to her history of fever.
B) That after her acute illness subsided to consider checking
crp, esr and nuclear medicine studies if all else was negative;
and to also consider checking anaplasma/ehrlichia serologies,
anca, [**Doctor First Name **], spep/upep and consider Rheumatological evaluation +/-
Oncology evaluation.
.
5) Maculo papular rash: The patient developed a rash across her
abdomen, back and all 4 extremities 4 days prior to her
discharge. The rash was thought to be part of a possible drug
reaction to penicillins although the timing was after she had
discontinued her zosyn. It was treated with benedryl and sarna
and almost completely resolved by the time of discharge.
.
6) Increased mediastinal lymphadenpathy and 5mm lung nodule on
CT as noted above - requires follow-up in [**4-30**] months.
Medications on Admission:
prilosec 20 mg daily
synthroid 75 mcg daily
lipitor
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Acute Renal Failure
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred here from an outside hospital for
evaluation of pancreatitis and pneumonia. Your pancreatitis
improved without further intervention. Your pneumonia was
treated with broad spectrum antibiotics. Your hospital course
was complicated by acute renal failure, which improved with IV
fluids. You had low-grade fevers until the end of your hospital
stay without a clear cause. You were seen in consultation by
our Infectious Disease specialists who recommended several blood
tests for look for a possible infection that may be causing your
fevers. All of these tests were negative, including Hepatitis B,
HIV, and an RPR test. You have a pending test for Hepatitis C
that you can check at your follow up appointment. The infectious
disease doctors recommended that [**Name5 (PTitle) **] get an echocardiogram of
your heart, but your fevers have gone away before this test
could be scheduled in the hospital. You should follow up with
your primary physician to consider whether an echocardiogram
should be done as an outpatient. A small lung nodule was seen on
your CT scan of your lungs that will need to be followed up with
your primary physician.
There have been no changes to your home medications.
Followup Instructions:
Please follow-up with your primary care doctor within one week
of discharge.
Department: [**Hospital3 249**]
When: FRIDAY [**2183-9-19**] at 9:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5845, 2760, 2449, 2720, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4705
} | Medical Text: Admission Date: [**2170-2-8**] Discharge Date: [**2170-2-14**]
Date of Birth: [**2104-9-15**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Amiodarone Hcl
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
- EGD [**2-9**]
- EGD [**2-13**] with APC of GAVE tissue
History of Present Illness:
65 year old male w/ hx of CAD s/p MI, chronic cardiomyopathy (EF
30% IN [**2167**]), afib (on warfarin), vtach (s/p pacer/ICD), HTN and
DMII presenting after a CBC blood draw by clinic that
demonstrated a precipitous drop (last in 9/[**2164**]). Pt was seen
by PC [**1-19**] with complaints of mild lightheadedness when
standing. No syncope or feelings of pre-syncope. He was seen [**Location 11973**] yesterday and had blood drawn which
revealed a Hct of 21. His previous hct was in [**8-/2165**] and was 40.
He was advised to come to walk-in today by the on call doctor.
Pt notes his stool over the past 3-4 days having specks of
charcoal stool but mainly yellow.Upon questioning, pt hasn't
taken any pepto-bismol, blueberries or iron supplementation. His
stool are usually completely yellow. He denies chest pain, sob,
abd pain. He denies use of pepto-bismol. He notes a slight nose
bleed 2-3 days ago but denies any other symptoms of gross
bleeding.
.
Patient is a non-drinker for 26 years and denies any NSAID
usage.
.
In the ED inital vitals were, 98.2 63 110/50 18 97%. The patient
had an NG lavage with red specks but no frank blood. Rectal exam
demonstrated brown, guaiac negative stool. GI was consulted and
will see in ICU. Pt was initiated on protonix bolus + gtt. Pt
given Vitamin K 10 mg IV once. Pt is a Jehovah's witness and
refuses blood products (patient was explicitly told that may die
with refusal of blood).
.
On arrival to the ICU, vital signs are afebrile 82 15 124/77
100% 2L. Patient in no acute distress. Communicating clearly
and coherently.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Myocardial infarction, coronary artery disease.
2. Chronic cardiomyopathy with LVEF of 30%.
3. Moderate mitral regurgitation.
4. Atrial fibrillation, on warfarin.
5. Nonsustained VT, status post ICD -- last device
interrogation [**11/2169**], w/ e/o atrial tachycardia up to atrial
rate of 300
6. Atrial tachycardia.
7. Diabetes.
8. Hypertension.
9. Gout.
10. Hyperlipidemia.
11. Anxiety.
Social History:
spanish speaker from [**Male First Name (un) 1056**], Jehova's Witness who will not
have any blood products
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No cancer. There is premature heart disease.
.
Physical Exam:
ADMISSION PHYSICAL EXAM;
Vitals: afebrile 82 15 124/77 100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (Mallampati 2)
Neck: supple, JVP 7cm H2O, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM
98.7, 106/58, 60, 20, 99RA FS 189
General: Alert, oriented, no acute distress, pale
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, NO JVP, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
.
[**2170-2-7**] 05:07PM BLOOD WBC-6.9 RBC-2.74*# Hgb-6.9*# Hct-21.6*#
MCV-79*# MCH-25.2*# MCHC-31.9 RDW-13.9 Plt Ct-257
[**2170-2-8**] 11:42AM BLOOD WBC-5.4 RBC-2.61* Hgb-6.6* Hct-20.4*
MCV-78* MCH-25.2* MCHC-32.3 RDW-14.1 Plt Ct-240
[**2170-2-9**] 05:55AM BLOOD WBC-6.1 RBC-2.76* Hgb-7.0* Hct-21.0*
MCV-76* MCH-25.3* MCHC-33.3 RDW-14.0 Plt Ct-245
[**2170-2-10**] 06:15AM BLOOD WBC-6.9 RBC-2.80* Hgb-7.1* Hct-21.6*
MCV-77* MCH-25.2* MCHC-32.6 RDW-14.4 Plt Ct-258
[**2170-2-11**] 06:25AM BLOOD WBC-8.4 RBC-2.98* Hgb-7.3* Hct-22.6*
MCV-76* MCH-24.4* MCHC-32.2 RDW-15.2 Plt Ct-261
[**2170-2-12**] 06:56AM BLOOD WBC-6.9 RBC-3.03* Hgb-7.5* Hct-23.2*
MCV-77* MCH-24.8* MCHC-32.4 RDW-16.3* Plt Ct-234
[**2170-2-13**] 07:27AM BLOOD WBC-7.0 RBC-2.90* Hgb-7.3* Hct-22.1*
MCV-76* MCH-25.1* MCHC-32.9 RDW-16.8* Plt Ct-240
[**2170-2-8**] 11:42AM BLOOD Neuts-56 Bands-0 Lymphs-29 Monos-10 Eos-3
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2170-2-8**] 12:40PM BLOOD PT-33.0* PTT-35.3 INR(PT)-3.2*
[**2170-2-8**] 11:07PM BLOOD PT-24.6* INR(PT)-2.4*
[**2170-2-9**] 05:55AM BLOOD PT-19.7* PTT-26.9 INR(PT)-1.9*
[**2170-2-10**] 06:15AM BLOOD PT-15.5* INR(PT)-1.5*
[**2170-2-13**] 07:27AM BLOOD PT-13.6* PTT-24.9* INR(PT)-1.3*
[**2170-2-7**] 05:07PM BLOOD UreaN-25* Creat-1.6* Na-132* K-5.2*
Cl-101 HCO3-24 AnGap-12
[**2170-2-8**] 11:42AM BLOOD Glucose-145* UreaN-26* Creat-1.3* Na-132*
K-4.6 Cl-99 HCO3-25 AnGap-13
[**2170-2-9**] 05:55AM BLOOD Glucose-137* UreaN-18 Creat-1.2 Na-135
K-4.4 Cl-102 HCO3-23 AnGap-14
[**2170-2-12**] 06:56AM BLOOD Glucose-133* UreaN-23* Creat-1.3* Na-136
K-4.6 Cl-104 HCO3-22 AnGap-15
[**2170-2-8**] 11:42AM BLOOD LD(LDH)-193 TotBili-0.3
[**2170-2-9**] 05:55AM BLOOD ALT-16 AST-20 LD(LDH)-181 AlkPhos-56
TotBili-0.5
[**2170-2-7**] 05:07PM BLOOD proBNP-1157*
[**2170-2-9**] 05:55AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.0 Mg-1.8
[**2170-2-8**] 11:42AM BLOOD calTIBC-446 Hapto-122 Ferritn-7.6*
TRF-343
[**2170-2-9**] 05:55AM BLOOD IgA-227
[**2170-2-9**] 05:55AM BLOOD tTG-IgA-4
.
CXR ([**2170-2-8**]):
A dual-lead pacemaker/ICD device appears unchanged with leads
again
terminating in the right atrium and ventricle, respectively. The
heart is
mildly enlarged. The mediastinal and hilar contours appear
unchanged. A
calcified nodule in the right upper lobe suggesting a granuloma
appears
unchanged. Otherwise, the lungs remain clear. There is no
pleural effusion
or pneumothorax. Small osteophytes are noted along the
mid-to-lower thoracic spine. IMPRESSION: No evidence of acute
disease.
.
ABDOMINAL ULTRASOUND:
Normal abdominal ultrasound. Normal liver.
.
EGD ([**2-9**]):
Findings:
Esophagus: Normal esophagus.
Stomach:
Flat Lesions Many non-bleeding localized angioectasias were seen
in the stomach antrum. The lesions were distributed in a
watermelon-stomach pattern, consistent with GAVE.
Duodenum: Normal duodenum.
Impression: Angioectasias in the stomach antrum, watermelon
stomach consistent with GAVE
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings account for the symptoms.
GAVE could not be treated during this endoscopy due to elevated
INR.
.
EGD with APC ([**2-13**]):
Normal mucosa in the esophagus
Angioectasias in the antrum (thermal therapy)
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Repeat endoscopy in [**3-30**] weeks for repeat APC.
Additional recs by inpatient GI team.
Brief Hospital Course:
65 yo M w/ CAD s/p MI, sCHF, AFIB, HTN and DMII presented with
four days of dark stools and several weeks of progressive
fatigue. Found to have marked iron-deficiency anemia likely
secondary to chronic bleeding and GAVE treated with EGD/APC on
[**2-13**].
.
# Anemia / GI bleed: Hct ~ 20 at presentation. He refuses
transfusion for religious reasons. His anemia is likely
secondary to both acute bleeding (dark stools) and slow chronic
loss (ferritin of 7). He has received two doses of IV iron
during this admission and is discharged on PO BID iron to be
continued until his iron stores are replete. GAVE tissue was
successfully treated with EGD/APC (cautery) and he will have to
follow-up in two weeks for repeat EGD/APC. As discussed with
his PCP and GI, he will hold coumadin until at least after this
procedure in two weeks.
.
# Chronic Systolic CHF Last EF 30% in [**2167**], followed by Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Hospital1 18**] who was notified at the time of admission.
Continued home valsartan, lasix, spironolactone, carvedilol
throughout his hospital stay and at discharge. He remained
euvolemic during this admission.
.
# CAD: It is unclear why this diabetic gentleman is not on
aspirin for CAD. Given that he has never been on this, I am
hesitant to start it this soon after his gastric bleed. Would
favor starting it along with coumadin when hae follows-up after
the EGD/[**Last Name (un) **].
.
# Atrial Fibrillation: CHADS2 score is 3. Given his refusal of
blood, Hct of 20, and high risk for re-bleed as above, have
advised him to hold coumadin until after the repeat APC and
colonoscopy.
.
CHRONIC INACTIVE ISSUES:
# DMII: Continued metformin. Pt's most recent HA1c = 7.3
([**11-4**]).
# Chronic Renal Insufficiency: Pt w/ Cr 1.6 --> 1.3 --> 1.2.
Most recent Cr 1.4 in [**2169-10-24**].
# Gout: stable, continued colchicine
# Anxiety: continued klonopin
.
Medications on Admission:
AMMONIUM LACTATE - 12 % Cream - apply to feet twice a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day for cholesterol
BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth four times
a
day as needed for cough
CARVEDILOL - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 1 Tablet(s) by mouth one
in am, one i pm and 2 qhs as needed for anxiety
COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as needed up
to
twice a day prn
DOFETILIDE - 500 mcg Capsule - 1 Capsule(s) by mouth q 12 h
ECONAZOLE - 1 % Cream - apply [**Hospital1 **] to rash on back and chest x 6
weeks disp at least 60gram tube
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 puff each
nostril once a day for allergies/running nose
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day for swelling and blood pressure
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day for
diabetes (also called GLUCOPHAGE)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 (One) Tablet(s) by mouth once a day brand name only
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - Apply twice daily to
affected areas for up to 2 weeks/month max twice a day as needed
for AVOID face and folds
VALSARTAN [DIOVAN] - 80 mg Tablet - 1 Tablet(s) by mouth twice a
day
WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth as directed blood
thinner
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test
twice a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
PEG 400-PROPYLENE GLYCOL [LUBRICANT EYE (PEG-PEG 400)] - 0.3
%-0.4 % Drops - 1 drop(s) each eye three times a day
SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 1 OR 2
Tablet(s) by mouth at bedtime as needed for constipation
Discharge Medications:
1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. benzonatate 200 mg Capsule Sig: One (1) Capsule PO four times
a day as needed for cough.
3. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Klonopin 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day.
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for gout.
6. dofetilide 500 mcg Capsule Sig: One (1) Capsule PO twice a
day.
7. Flonase 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal once a day.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
12. valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day.
13. multivitamin Oral
14. peg 400-propylene glycol 0.4-0.3 % Drops Sig: One (1)
Ophthalmic three times a day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
- UPPER GI BLEED secondary to GAVE SYNDROME (Gastric Antral
Vascular Ectasia)
- IRON DEFICIENCY ANEMIA
- CHRONIC SYSTOLIC HEART FAILURE
- DIABETES TYPE 2 CONTROLLED, COMPLICATED
- CORONARY ARTERY DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with severe anemia which seems
to have been caused by abnormal tissue in your stomach which was
treated with endoscopy and cautery. You were given intravenous
iron to address your severe iron deficiency anemia. You have
received a prescription for oral iron twice daily which you
should take until your primary care doctor tells you to stop.
Pantoprazole has been increased to 40mg twice daily--you have
received a prescription for this. You should take this
increased dose for at least 4-6 weeks and can discuss the
ultimate duration with your PCP.
You should continue to hold coumadin until your PCP tells you to
restart it after your EGD/colonoscopy (which is scheduled in two
weeks). As we discussed, you take coumadin to lower your risk
of stroke from atrial fibrillation. The risk of anticoagulating
you with the degree of anemia you already have and because we
cannot transfuse you (for religious reasons) is too high
currently.
You should be on Aspirin for your coronary disease and diabetes.
Now is not the time to start given the very recent bleeding, but
you should discuss starting this eventually with your PCP.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
SUMMARY OF MEDICATION CHANGES:
- STOP COUMADIN until Dr. [**Last Name (STitle) 8499**] tells you to re-start
- INCREASE PANTOPRAZOLE TO TWICE DAILY
- START IRON TWICE DAILY
Followup Instructions:
WE HAVE SCHEDULED THIS APPOINTMENT WITH YOUR PCP FOR YOU:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2170-2-22**] at 3:45 PM
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
YOU HAVE A COMBINE EGD & COLONOSCOPY SCHEDULED FOR:
WEDNESDAY [**2170-2-28**] with Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**] at 1:00pm in the
[**Hospital1 18**] [**Hospital Ward Name **]. You will be contact[**Name (NI) **] regarding preparation
for the procedure.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2170-2-14**]
ICD9 Codes: 4254, 2851, 4280, 4240, 5859, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4706
} | Medical Text: Admission Date: [**2169-6-7**] Discharge Date: [**2169-6-14**]
Date of Birth: [**2097-9-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Jaw pain, palpitations
Major Surgical or Invasive Procedure:
[**2169-6-7**] Aortic Valve Replacement(21mm CE Magna Pericardial) and
Four Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending with saphenous vein
grafts to firt obtuse marginal, second obtuse marginal and right
coronary artery)
History of Present Illness:
This is a 71 year old male with PMH significant for
hypertension, hypercholesterolemia, known CAD s/p RCA stent [**2158**]
with recurrent anginal symptoms who presents for cardiac
catheterization. He reports jaw pain accompanied by occasional
palpitation with exertion/ambulation that resolve with rest. He
states that he had anginal episodes while residing in [**State 108**]
over the winter, but did not seek medical care. Upon return from
[**State 108**], he reported these symptoms to his cardiologist who
referred patient for cardiac catheterization which revealed
severe three vessel coronary artery disease including a 70% left
main lesion. Outside echocardiogram also showed moderate aortic
stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.4cm2 and gradients of 51 and 29mmHg
respectively. Given the above findings, he was referred for
cardiac surgical intervention.
Past Medical History:
Aortic Stenosis
Hypertension
Hypercholesterolemia
Paroxysmal Atrial Fibrillation
CAD s/p RCA Tristar stent [**2158**]
Renal stones s/p lithotripsy
DVT x2 ([**2164**], [**2165**]) treated with coumadin for 3 months
GERD
BPH
s/p tonsillectomy
s/p back surgery [**2164**]
s/p bilat ocular lens implants
Social History:
Last Dental Exam: >1 yr ago
Lives with: wife
Occupation: retired truck driver
Tobacco: denies
ETOH: social
Family History:
Family History: Mother died of MI age 63, Brother died age 50 of
CVA, Son had MI age 42, subsequent CABG, and died at age 46 of
MI (1.5 years ago)
Physical Exam:
On admission:
Pulse:59 Resp:14 O2 sat: 98%RA
B/P Right:132/71 Left: 173/74
Height: 5'[**68**]" Weight: 225lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] IV/VI cres-decres systolic murmur
Abdomen: Soft/non-distended/non-tender [x]
Extremities: Warm/well-perfused [x] Edema Varicosities: None
[x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: (-) Left: (-)
Pertinent Results:
[**2169-6-7**] Intraop TEE:
PRE BYPASS The left atrium is mildly dilated. The left atrium is
elongated. Mild spontaneous echo contrast is present in the left
atrial appendage. No thrombus is seen in the left atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and global systolic function (LVEF>55%). 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. The aortic valve leaflets are moderately thickened and
immobilized. There is mild to moderate aortic valve stenosis
(valve area 1.4cm2). Trace to mild aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. 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 being a-paced. There is normal left
ventricular systolic function. Right ventricular systolic
function is low normal - slightly depressed compared to
pre-bypass finding. There is a bioprosthesis located in the
aortic position. It appears well seated. The leaflets are only
very poorly seen. The maximum gradient through the valve is 27
mmHg with a mean presssure of 18 mmHg at a cardiac output of 4.5
liters/minute. The effective orifice area of the valve is about
1.6 cm2 - slightly less then expected for this valve. The mitral
regurgitation is worsened -compared to pre-bypass. It is
moderate in intensity and centrally directed. The thoracic aorta
appears intact. No other significant changes from the pre-bypass
study.
[**2169-6-13**] Chest X-ray:
FINDINGS: Seven midline sternotomy wires, intact. There is a
right IJ in place with tip at the low SVC, in standard position.
There is no focal lung consolidation. There is stable enlarged
cardiomediastinal silhouette. There are stable bilateral small
pleural effusions. There is subtle bibasilar atelectasis of the
lung bases. There is retrocardiac opacity, which is stable,
likely atelectasis. There is new mild engorgement of the
pulmonary vasculature, suggesting new mild pulmonary edema.
IMPRESSION: 1. New mild pulmonary edema, with bilateral small
pleural effusions, and bibasilar atelectasis, and retrocardiac
atelectasis. 2. Stable cardiomegaly.
BLOODWORK:
[**2169-6-14**] WBC-9.6 RBC-3.80* Hgb-11.3* Hct-35.1* Plt Ct-254
[**2169-6-13**] WBC-9.0 RBC-3.56* Hgb-11.0* Hct-32.8* Plt Ct-218
[**2169-6-12**] WBC-9.3 RBC-3.69*# Hgb-11.0*# Hct-33.9* Plt Ct-184#
[**2169-6-11**] WBC-8.0 RBC-2.46* Hgb-7.6* Hct-22.9* Plt Ct-120*
[**2169-6-10**] WBC-10.4 RBC-2.88* Hgb-8.9* Hct-27.0* Plt Ct-103*
[**2169-6-13**] PT-21.5* INR(PT)-2.0*
[**2169-6-12**] PT-19.0* INR(PT)-1.7*
[**2169-6-11**] PT-15.7* INR(PT)-1.4*
[**2169-6-10**] PT-13.0 INR(PT)-1.1
[**2169-6-14**] UreaN-34* Creat-1.3* Na-139 K-4.0 Cl-98
06/15/10UreaN-37* Creat-1.4* Na-140 K-3.9 Cl-101
[**2169-6-12**] Glucose-103* UreaN-41* Creat-1.4* Na-138 K-4.1 Cl-99
HCO3-29
[**2169-6-11**] Glucose-104* UreaN-47* Creat-2.0* Na-136 K-4.3 Cl-100
HCO3-28
[**2169-6-10**] Glucose-127* UreaN-50* Creat-2.6* Na-134 K-4.5 Cl-99
HCO3-28
[**2169-6-10**] Glucose-95 UreaN-47* Creat-2.6* Na-135 K-4.8 Cl-100
HCO3-26
[**2169-6-9**] UreaN-39* Creat-2.5* Na-135 K-5.0 Cl-100
[**2169-6-9**] Glucose-97 UreaN-36* Creat-2.2* Na-133 K-5.0 Cl-100
HCO3-25
[**2169-6-9**] Glucose-124* UreaN-30* Creat-1.8* Na-135 K-4.5 Cl-103
HCO3-25
[**2169-6-14**] Mg-2.1
[**2169-6-13**] Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 24642**] was admitted and underwent aortic valve
replacement and coronary artery bypass grafting surgery. See
operative note for details. Following surgery, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically and was extubated without incident. He
experienced intermittent bouts of rapid atrial fibrillation and
was started on Amiodarone in addition to beta blockade. He
otherwise maintained stable hemodynamics and transferred to the
SDU on postoperative day two. Due to persistent bouts of
paroxsymal atrial fibrillation, Coumadin was started and dosed
for a goal INR between 2.0 and 2.5. Due to postoperative blood
loss, he was transfused with packed red blood cells to maintain
hematocrit near 30%. Over several days, beta blockade was
advanced for rate control and medical therapy was optimized.
Amiodarone was slowly titrated accordingly. He continued to make
clinical improvements with diuresis and was eventually cleared
for discharge to home on postoperative day seven. At discharge,
his INR was therapeutic and Coumadin followup was arranged and
confirmed with Dr. [**Last Name (STitle) **] via his medical assistant [**Doctor Last Name **].
At discharge, all surgical incisions were clean, dry and intact.
Medications on Admission:
Zetia 10mg po daily
Lisinopril 5mg po daily
Metoprolol Succinate 50mg po daily
Simvastatin 20mg po daily
ASA 325mg po daily
Vit D3 1000 units po daily
Glucosamine-Chondroitin 500mg-400mg capsule po daily
MVI 1 tab daily
Fish Oil 1000mg po BID
Flomax- new prescription, hasn't started yet
Discharge Medications:
1. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Doctor Last Name **]:*60 Capsule(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
[**Doctor Last Name **]:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Doctor Last Name **]:*30 Tablet(s)* Refills:*2*
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Doctor Last Name **]:*30 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Doctor Last Name **]:*30 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Doctor Last Name **]:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Doctor Last Name **]:*60 Capsule(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Doctor Last Name **]:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Doctor Last Name **]:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
[**Doctor Last Name **]:*120 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: then drop to 40mg daily for one week then discontinue. .
[**Doctor Last Name **]:*21 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then drop to 200mg daily until follow up with MD.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*1*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Daily dose may vary according to PT/INR. Goal INR between 2.0 to
2.5. Dr. [**Last Name (STitle) **] will titrate accordingly.
[**Last Name (STitle) **]:*60 Tablet(s)* Refills:*1*
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Hypertension
Dyslipidemia
History of Paroxysmal Atrial Fibrillation
History of Deep Vein Thrombosis
Postop Acute Blood Loss Anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions: Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 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**
Followup Instructions:
Dr. [**First Name (STitle) **] on [**2169-7-10**] on 1:45PM
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**12-31**] weeks, call for appt
Dr. [**Known firstname **] [**Last Name (NamePattern1) 5310**] in [**12-31**] weeks, call for appt
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2169-6-14**]
ICD9 Codes: 4241, 5849, 2851, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4707
} | Medical Text: Admission Date: [**2131-6-16**] Discharge Date: [**2131-6-20**]
Date of Birth: [**2056-3-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
s/p dual chamber [**Company 1543**] Adapta PM via left cephalic
History of Present Illness:
This is a 75 year old male with a history of CAD with stents
placed in [**2127**] at [**Hospital6 **],
Per family, Mr [**Known lastname **] was having chest pain while sitting in the
chair, as well as feeling lightheaded. He then passed out for
10-20 seconds. EMS was called and found him looking pale and
lethargic. While EMS was assessing, he became unresponsive with
eyes rolling back in head with 20 second convulsions for
approximately 20 seconds before returning to normal
consciousness. Denied chest pain. A telemetry monitor was
placed and was noted to be in 3rd degree heart block with rates
10-30 beats per minute. A transcutaneous pacer was placed on
route.
Past Medical History:
-coronary disease s/p stent placement
-diabetes mellitus
-hypertension
-hyperlipidemia
-gout
-type II diabetes
-sleep apnea
-osteoarthritis
-depression
Social History:
occasional EtOH use
Family History:
n/c
Physical Exam:
BP 118/71, HR 80, RR 16, SpO2 100% on assist control PEEP 5 FiO2
50%
Gen: Sedated, intubated, in no apparent distress
Cardiac: Nl s1/s2, regular rate and rhythm, no murmurs
appreciable, no s3/s4
Resp: lungs clear in anterior lung fields
Abd: soft and nontender, +BS
Ext: 1+ lower extremity edema, pulses 1+ distally, warm and
well-perfused
Pertinent Results:
Admission labs:
[**2131-6-16**] 03:55PM BLOOD WBC-7.8 RBC-4.06* Hgb-11.4* Hct-35.4*
MCV-87 MCH-28.0 MCHC-32.1 RDW-16.2* Plt Ct-154
[**2131-6-16**] 03:55PM BLOOD Neuts-76.5* Lymphs-17.9* Monos-4.4
Eos-0.8 Baso-0.3
[**2131-6-16**] 03:55PM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1
[**2131-6-16**] 03:55PM BLOOD Glucose-91 UreaN-41* Creat-1.5* Na-144
K-6.0* Cl-112* HCO3-24 AnGap-14
[**2131-6-16**] 03:55PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
[**2131-6-16**] 03:55PM BLOOD TSH-2.0
.
Cardiac Enzymes:
[**2131-6-16**] 03:55PM BLOOD CK-MB-3 cTropnT-<0.01
[**2131-6-17**] 04:00AM BLOOD CK-MB-3 cTropnT-LESS THAN
.
Discharge labs:
[**2131-6-20**] 01:20PM BLOOD WBC-9.4 RBC-3.79* Hgb-10.8* Hct-33.2*
MCV-88 MCH-28.5 MCHC-32.6 RDW-16.1* Plt Ct-165
[**2131-6-20**] 06:55AM BLOOD Glucose-128* UreaN-53* Creat-1.8* Na-137
K-4.7 Cl-103 HCO3-25 AnGap-14
[**2131-6-20**] 06:55AM BLOOD Mg-2.3
.
[**2131-6-16**] Echo:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 45%). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction, c/w CAD. Mild mitral
regurgitation.
.
[**2131-6-16**] CT head:
No acute intracranial hemorrhage or mass effect.
.
[**2131-6-16**] CXR:
There is moderate cardiomegaly. ET tube tip is 4.3 cm above the
carina.
Pacer tip is in the right ventricle. There is no evident
pneumothorax or
pleural effusions. Aside from minimal atelectasis in the left
base, the lungs are clear. There is marked distention of the
stomach.
.
[**2131-6-18**] CXR:
The external pacer terminates in the right ventricle.
Cardiomediastinal
silhouette is stable. There is overall improvement of the basal
aeration.
The upper lungs are also unremarkable. No appreciable pleural
effusion is
demonstrated as well as no definitive evidence of pneumothorax
is present.
Brief Hospital Course:
This is a 75 year old male with a known history of CAD with
prior inferior wall MI who now presents with syncope likely
secondary to complete heart block
.
# Syncope/Symptomatic Bradycardia: Episode secondary to complete
heart block noted on telemetry at time of event. Patient was
intubated for airway protection and a temporary transcutaneous
pacer was placed. Cardiac enzymes were negative and TSH normal.
A head CT was done to rule out CNS bleed. An echocardiogram was
also done that showed mild regional systolic dysfunction, c/w
CAD, mild MR, EF 45%. [**6-16**] patient was extubated. A permanent
[**Company **] pacemaker was placed on this admission.
.
# CAD: Cardiac markers were negative on admission. Echo showed,
mild regional systolic dysfunction c/w CAD. Once head bleed was
ruled out he was continued on aspirin, plavix. His
ace-inhibitor was continued. Nodal agents were initially held,
given the heart block. Post-pacemaker placement, he was
restarted on amlodipine. He was switched from atenolol to
carvedilol.
.
# Diabetes mellitus: Patient continued on ISS. He currently
takes no medicines at home for glucose control.
.
# Hyperlipidemia: Continuec statin
.
# Gout: Patient complained on knee pain consistent w/ his prior
history of gout. He was treated with a short course of
prednisone.
.
# HTN: PCP confirmed that patient was supposed to switched from
HCTZ to chlorthalidone. This was held given his suspected gout
flare. He was treated with ace-i, ccb, and atenolol switched to
carvedilol (see above).
.
# Chronic Renal Insufficiency: Based on atrius records, patient
noted to have renal complications of diabetes with a Creatine of
1.7 for the past several years. His Cr at [**Hospital1 18**] ranged from
1.5-1.8.
.
# Anemia: No obvious signs of bleeding. Pt has not had a BM here
and rectal exam negative for impaction with negative guiaic.
Iron studies show mild Fe deficiency. Ferrous sulfate started at
discharge with instructions for repeat CBC on [**6-23**]. His PCP
was made aware of plan.
Medications on Admission:
-chlorthalidone 12.5 mg daily
-simvastatin 40 mg qhs
-flomax 0.4 mg PO daily
-allopurinol 100 mg PO BID
-hydrochlorothiazide 25 mg daily
-isosorbide dinitrate 10 mg PO BID
-plavix 75 mg daily
-atenolol 50 mg po daily
-atenolol 25 mg po qpm
-amlodipine/benzapril 10 / 20 mg daily
-lorazepam 0.5 mg [**Hospital1 **] PRN anxiety
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Amlodipine-Benazepril 10-20 mg Capsule Sig: One (1) Capsule
PO once a day.
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
15. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check Chem-7 and CBC on Friday [**6-23**] with results to
Dr. [**Last Name (STitle) **]
17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily). Tablet(s)
18. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO DAILY (Daily).
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart Block status post Pacemaker
Coronary Artery Disease
Gout
Hypertension
Hyperlipidemia
Anemia
Chronic Kidney 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 complete heart block which is due to a deterioration of
the electrical system of your heart. This caused a very slow
heart rate and you received a pacemaker to keep your heart rate
at a normal level. You will need to avoid showers for 3 days and
keep the pacer site dry. On Saturday you can take the dressing
off and take a shower, pat the area dry. You will be seen in the
[**Hospital1 **] Device clinic in 1 week to check the pacer. No
lifting your left arm over your head or lifting more than 5
pounds for 6 weeks. No driving until after your device clinic
appt. Please see the pacemaker booklet for further instructions.
You were found to have some anemia but your blood counts are
stable today. Please get labs checked on Friday [**6-23**] and
take iron to help your blood counts improve.
.
Medication changes:
1.Start Prednisone to treat a gout flare for a total of 5 days.
2. Start Keflex, an antibiotic to prevent an infection at the
pacer site.
3. Start Oxycodone for your knee pain and Tylenol if you have
pain at the pacer site.
4. Stop chlorthalidone
5. Stop Atenolol, start Carvedilol at 12.5 mg twice daily for
your blood pressure.
6. Start Ferrous sulfate to help your anemia. You will need to
take colace, a stool softener, and Miralax if you get
constipated. These all are over the counter medicines.
Followup Instructions:
DEVICE CLINIC: [**Hospital1 **] office will call you with an
appt for next week.
.
Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 2258**] Date/Time:
[**Hospital1 **] office will call you with an appt.
Primary Care:
[**Last Name (LF) 41941**],[**First Name3 (LF) **] J. Phone: [**Telephone/Fax (1) 31019**] Please call Dr [**Last Name (STitle) **] when you
get home to schedule an appt in 2 weeks.
Completed by:[**2131-6-20**]
ICD9 Codes: 5859, 412, 2724, 2749, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4708
} | Medical Text: Admission Date: [**2145-4-10**] Discharge Date: [**2145-4-10**]
Date of Birth: [**2125-4-18**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
heroin overdose
Major Surgical or Invasive Procedure:
s/p intubation
s/p cvc placement
History of Present Illness:
see brief hospital course
Past Medical History:
see brief hospital course
Social History:
see brief hospital course
Family History:
see brief hospital course
Physical Exam:
see brief hospital course
Pertinent Results:
[**2145-4-10**] 07:37AM TYPE-ART PO2-82* PCO2-67* PH-6.87* TOTAL
CO2-14* BASE XS--23
[**2145-4-10**] 06:27AM TYPE-ART PO2-61* PCO2-86* PH-6.79* TOTAL
CO2-15* BASE XS--26
[**2145-4-10**] 06:27AM GLUCOSE-201* LACTATE-10.5* NA+-135 K+-7.1*
CL--108
[**2145-4-10**] 06:27AM HGB-15.4 calcHCT-46 O2 SAT-72
[**2145-4-10**] 06:27AM freeCa-1.10*
SINGLE SUPINE AP PORTABLE CHEST RADIOGRAPH: An endotracheal tube
is in
optimal position terminating 3.5 cm above the carina. A
nasogastric tube
coils within the stomach,with the tip terminating in the distal
stomach. No
pneumothorax or large pleural effusions are seen. There is
diffuse opacity
overlying the entire right lung and major portion of the left
upper lung,
which likely represent diffuse pulmonary edema, ARDS or
hemorrhage. No acute
osseous abnormality seen.
IMPRESSION: Diffuse opacities in the right lung and left upper
lung, likely
represents pulmonary edema, ARDS or hemorrhage. ET tube in
optimal position.
Brief Hospital Course:
TITLE: Medical ICU Resident/MERIT Admission Note
Reason for transfer to the MICU: post-arrest management
History of Present Illness and MICU Course: Mr. [**Known lastname 12303**] is a 19
year old male with a history of polysubstance abuse most
significant for intravenous heroin, who presented to the [**Hospital1 18**]
ED for post-cardiac arrest care in the setting of an apparent
heroin overdose. He was transferred from [**Hospital3 **].
Briefly, he was discharged from a rehab center in [**State 108**] one
day prior to admission. Last night, at 3AM on [**2145-4-10**], his
mother found him down with needles around. She immediately
called 911 and initiated CPR. He was intubated in the field per
the [**Location (un) 5700**] service ambulance record and dopamine and levofed
were initiated; his pupils were reportedly fixed and dilated at
that point. Patient cooling was also performed via ice packs. At
[**Hospital3 **], advanced cardiopulmonary life support was
continued for over 40 minutes at which point the patient
regained a pulse. His labs at [**Hospital1 **] were notable for a WBC
14.2, Hct 45.2, Plt 210. Sodium 145, k 6.5, cl 107, co2 14,
gluc 247, bun 19, cr 2.3, ca [**43**]. He was then transferred to the
[**Hospital1 18**] ED. In the [**Hospital1 18**] ED he was on three pressors (epinephrine,
levophed, and vasopressin). His blood cases were checked twice
and showed 6.79/86/61 -->6.87/67/82. He was transferred to the
MICU. In the MICU, he did not have a femoral pulse. A cardiac
monitor was placed and he was noted to have pulseless electrical
activity. ACLS was initiated. He received sodium bicarbonate,
calcium chloride, d50, NS, and boluses of epinephrine. His
rhythm converted to ventricular fibrillation and he was shocked.
He then converted to PEA and regained a pulse after another
bolus of epinephrine. The family was present. The code lasted
just under ten minutes. After discussion with the family, the
decision was made not to escalate care (see Dr. [**Last Name (STitle) **]??????s note).
He remained on three pressors with ventilatory support. Within
one hour he became bradycardic and expired. See written death
note in the chart. The organ bank declined the case for
donation. The Medical examiner accepted the case. The family
declined discretionary autopsy. Death report and other necessary
documentation was filed.
Medications on Admission:
see brief hospital course
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2145-5-12**]
ICD9 Codes: 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4709
} | Medical Text: Admission Date: [**2141-3-15**] Discharge Date: [**2141-3-22**]
Date of Birth: [**2141-3-15**] Sex: F
Service: NB
HISTORY: Baby girl [**Name2 (NI) 72061**] [**Known lastname **] delivered at 32 and 4/7 weeks
gestation with a birth weight of 1860 gm and was admitted to
the newborn intensive care nursery from labor and delivery
for management of prematurity.
Mother is a 20-year-old gravida 1 mother with estimated date
of delivery [**2141-5-6**]. Her prenatal screens included
blood type A+, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella-immune, and group B Strep
unknown. This mother was a maternal transfer from [**Name (NI) 6687**].
Her history is notable for an anxiety disorder treated with
Ativan. This pregnancy was complicated by pregnancy-induced
hypertension treated with labetalol. She developed
preeclampsia treated with magnesium sulfate and was given a
full course of betamethasone. Due to worsening preeclampsia
labor was induced, however, due to fetal intolerance of labor
the delivery was by cesarean section under epidural spinal
anesthesia. There was no maternal fever. Membranes ruptured
around 9 hours prior to delivery for clear fluid. She
received intrapartum vancomycin for about 8 hours prior to
delivery for unknown group B Strep.
[**Name (NI) 72061**] emerged vigorous and crying. She received trying and
bulb suctioning. Apgar scores were 9 and 9 at one and five
minutes respectively.
PHYSICAL EXAM ON ADMISSION: Weight 1860 gm (50th-75th
percentile), length 42.5 cm (25th-50th percentile), head
circumference 29.5 cm (25th-50th percentile). In general: A
pink, active infant in no respiratory distress. Non
dysmorphic, anterior fontanelle soft, flat, palate intact.
Neck supple, clavicles intact. Lungs clear, no grunting,
flaring or retracting, fair aeration, equal breath sounds.
Regular rate and rhythm without murmur, 2+ femoral pulses.
Abdomen soft with bowel sounds, no hepatosplenomegaly, no
masses. GU: Normal preterm female. Patent anus, no sacral
anomalies, hips stable. Left foot with overlapping toes and
smaller compared to the right foot, but without erythema or
discoloration, probably due to unusual positioning. Tone was
good with normal strength and moves all extremities equally.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: No
respiratory distress, has remained on room air throughout
hospitalization with respiratory rates in the 30s-50s. She
has had [**3-13**] brief apnea/bradycardia episodes per day not
requiring medication.
Cardiovascular: Her heart rates have ranged in the 120s-160s,
there has been no heart murmur. Her most recent blood
pressure is 76/51 with a mean of 61.
Fluids, electrolytes, nutrition: Was initially on IV fluids,
10% dextrose. Enteral feeds were initiated on day of life 1
with Similac Special Care 20 calories or expressed breast
milk when available. She has advanced daily on feeds and
reached full volume feeds on day of life 5 without problems.
[**Name (NI) **] calories were increased yesterday on [**2141-3-21**] to
breast milk or Special Care at 22 calories per ounce with a
plan to increase to 24 calories per ounce on day of transfer.
Her most recent electrolytes were done on [**2141-3-16**], her
sodium was 137, potassium 3.7, chloride 102, CO2 23. She is
voiding and stooling appropriately. Discharge weight: 1735
gm.
GI: Her bilirubin on day of life 3: Total 8.1 mg%, direct 0.3
mg%. Phototherapy was started on that day and then was
discontinued on day of life 6 ([**2141-3-21**]) with her
bilirubin total of 5.6 mg%, direct 0.3 mg%. A rebound
bilirubin was drawn on [**3-22**] which is day of life 7,
her total was 6.5 mg%, direct 0.3 mg%. Phototherapy was not
restarted.
Hematology: Hematocrit on admission 47.4%. She has not
received any blood products during this hospital stay.
Infectious disease: A CBC and blood culture was drawn on
admission, the white count was 12.8 with 53 polys, no bands,
platelets 375,000, hematocrit 47.4. She did not receive
antibiotics, the blood culture remained negative.
Neurology: Her exam is age-appropriate, a head ultrasound is
not indicated.
Dermatology: She was noted to have a white forelock that has
not been evaluated during her [**Hospital3 **] hospital stay.
Sensory: Hearing screen has not be performed, will need prior
to discharge home.
Ophthalmology: Exam is not indicated.
Psychosocial: Family lives on [**Hospital1 6687**] and is anxious for
transfer closer to home.
CONDITION ON DISCHARGE: A 7 day old, now 33 and 4/7 weeks
post conceptual age infant who is tolerating feedings,
resolving hyperbilirubinemia with apnea and bradycardia
prematurity.
DISCHARGE DISPOSITION: Transfer to [**Hospital6 33**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **], [**Street Address(2) 72062**], [**Hospital1 6687**], [**Numeric Identifier 72063**], phone number 1-[**Telephone/Fax (1) 72064**], fax 1-[**Telephone/Fax (1) 49370**].
CARE AND RECOMMENDATIONS:
1. Feeds: Breast milk with human milk fortifier 22 calories
per ounce or Similac Special Care liquid 22 calories per
ounce. Recommend advance calories to 24 calories per
ounce.
2. Medications: Currently on no medications, recommend iron
supplementation 2 mg/kg per day.
3. State newborn screen was sent on day of life 3 and is
pending.
4. Hearing screen is recommended because of preterm birth and
white forlock.
5. She has not received any immunizations.
6. Immunizations recommended: Synergist RSV prophylaxis to
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria:
1. Born at less than 32 weeks.
2. Born between 32-35 weeks with 2 of the following:
Daycare during RSV season, smoke in the household,
neuromuscular disease, airway abnormalities, or
school age siblings or #3 with chronic lung disease.
3. 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 a
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
DISCHARGE DIAGNOSES:
1. Adequate for gestational age 33 and 4/7 weeks preterm
female.
2. Apnea of prematurity.
3. Indirect hyperbilirubinemia.
4. Sepsis ruled out without antibiotics.
5. White forelock.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (Titles) 72065**]
MEDQUIST36
D: [**2141-3-22**] 13:23:02
T: [**2141-3-22**] 14:45:00
Job#: [**Job Number 72066**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4710
} | Medical Text: Admission Date: [**2191-9-26**] Discharge Date: [**2191-9-30**]
Date of Birth: [**2118-4-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
altered mental status and fever
Major Surgical or Invasive Procedure:
Lumbar puncture [**9-26**]
History of Present Illness:
Pt. was in USOH until 6.30pm on the night prior to admission,
when he felt generally fatigeud and ill. He noted to have had a
low grade fever and took a nap. At 8.30, his wife heard
grunting noises from bedroom, as she arrived, she noted that he
could not get OOB despite attempts. He was able to answer some
of her questions, but was "confused" some of his words were part
of normal volcabulary, but did not make sense situationally.
After ~ 20 mins, he was eventually able to get OOB and walk to
kitchen. He was able to drink a glass of water, however wife
noted that he continued to not be himself (he did not know how
to check his BG which he does regularly). She then noted again
that he appeared weak (stumbling in the room, from side to
side). She helped him to a chair, where he was unable to
support himself and slumped down. He was able to respond to
her, however, again was felt to be confused. There was no
aphasia, he did not have anomia, his words were no "gibberish"
but simply did not make sense in the context. He did not have
any premontory sx, no auras, no shaking, no incontinence, no
tongue biting. No prior episodes like this before. No HA, no
neck stiffness, phono/photophobia. No recent travel, no
exposures.
.
In the ED, initial vs were: 100.2 90 137/65 15 98% 4L NC.
Patient was noted to have a WBC given 16K, INR 2.3, Cr 1.8 and
Troponin of 0.02. He underwent CXR and CT head that were
negative for infection and ICH respectively. He was found to
have an oral temp of 103.9F and noted to have SBPs drop to high
80s. He received 4L NS, 1g of tylenol, Vancomycin 1g,
CeftriaXONE 1g, Aspirin 325mg, and Neutra-Phos Powder Packet 1.
.
On the floor, VS were 97.7F 89/56 84 96% 3LNC. Pt. was alert
and oriented x3, however w/ mild recall deficit.
Past Medical History:
- Afib
- HL
- DM
- CKD, stage unknown.
Social History:
LIves in [**Location **] w/ wife. [**Name (NI) **] [**Name2 (NI) **] in computer training,
website design and sales.
- Tobacco: pipe, quit 25yrs ago.
- Alcohol: 2d/wk
- Illicits: denies.
Family History:
No CAD,MI.
Gfa/Gmo - CVA
Breast cancer/BRCA mutation in multiple female family members.
Physical Exam:
VS: 97.7F 89/56 84 96% 3LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, + JVD.
Lungs: crackles at bases.
CV: [**Last Name (un) 3526**]/[**Last Name (un) 3526**], normal S1 + S2, no murmurs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, trace edema b/l to 1/2 up shins, 2+
pulses, no clubbing, cyanosis or edema
NEURO:
MS: alert, oriented x 3. Attn: DOWb in 7 seconds. Naming intact
to low and high frequency objects, repetition intact, [**Location (un) 1131**]
and writing intact. No evidence of apraxia or neglect.
Registration intact, recall at 5 mins [**1-2**].
CNs: VFF to confront, EOMi, PERRL, face symmetric, intact to LT,
tongue and palate midline/symmetric, shoulder shrug intact.
Motor: normal tone, nl. bulk. UEs [**5-4**] in UMN distribution and
[**5-4**] at IP/H/TA in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l. No pronator drift. DTRs 1+ at
[**Hospital1 **]/tri, 1+ at patella b/l. Toe down on R, equivocal on L. FNF
and HKS intact. Gait deferred.
Pertinent Results:
Admission labs
[**2191-9-25**] 10:20PM BLOOD PT-24.6* PTT-28.9 INR(PT)-2.3*
[**2191-9-25**] 10:20PM BLOOD WBC-16.4* RBC-4.48* Hgb-13.8* Hct-39.9*
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.8 Plt Ct-190
[**2191-9-25**] 10:20PM BLOOD Glucose-160* UreaN-28* Creat-1.8* Na-134
K-5.0 Cl-99 HCO3-27 AnGap-13
[**2191-9-25**] 10:20PM BLOOD Calcium-10.0 Phos-0.7* Mg-1.8
[**2191-9-25**] 10:20PM BLOOD ALT-20 AST-27 AlkPhos-58 TotBili-1.1
[**2191-9-26**] 05:03AM BLOOD CK(CPK)-196
[**2191-9-26**] 03:55PM BLOOD LD(LDH)-259*
[**2191-9-25**] 10:20PM BLOOD cTropnT-0.02*
[**2191-9-26**] 05:03AM BLOOD CK-MB-3 cTropnT-<0.01
[**2191-9-26**] 05:03AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.5*
[**2191-9-25**] 10:33PM BLOOD Lactate-1.9
[**2191-9-26**] 10:16AM BLOOD Lactate-2.3*
Blood Cx ([**9-25**]) Pending
UCX [**9-25**] pending
CSF gram stain - no PMNs or organisms seen
CSF Cell count:
[**2191-9-26**] 10:48AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* Polys-0
Lymphs-67 Monos-30 Macroph-3
[**2191-9-26**] 10:48AM CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-91
Brief Hospital Course:
# Metabolic encephalopathy: Etiology unclear. Initial concern
was for embolic event vs. Seizure activity vs Menengitis. He
had a LP on [**9-26**] that was clear fluid and cell count/prelim gram
stain which was negative for menengitis. He also underwent an
EEG on [**9-26**] and results are pending as of [**9-27**]. Embolic event
secondary to A. fib was less likely given therapeutic INR (2.3).
Throughout the day on [**9-26**] pt's mental status improved and he
was lucid, A/O x3 and interactive by time of transfer to the
floor.
.
# Sepsis syndrome. Source of leukocytosis and fever unclear.
[**Name2 (NI) **] with septic physiology in the ED, but responded to IVF.
He did not require pressors. UA neg, CXR w/o focal infiltrate,
and LP did not show menengitis. He was initially started on
emperic treatment for menengitis (CTX 1g [**Hospital1 **] and Vanc) and
azithro for possible CAP on [**9-26**]. After LP came back negative,
CTX was changed to 1g daily for pna coverage, azithro was
continued, and vanc was d/c'd on [**9-27**]. LFTs were unremarkable,
and Bcx is pending from [**9-25**]. WBC trended down throughout [**Hospital Unit Name 153**]
stay as did his fevers.
# Hypotension. Likely due to septic physiology. Received 4 L
of IVF in the ED and pressures were stable throughout [**Hospital Unit Name 153**]
course. EKG w/o ischemic signs/changes, and troponin trended
down from 0.02 to 0.01. Also had elevated lactate of 1.9 on
[**9-25**] which actually increased to 2.3 on [**9-26**] but clinically
remained stable and no clinical concern for hypoperfusion.
.
# Volume overload by CXR and lung exam on [**9-27**], likely [**2-1**] to
IVF. (+6L over last 24 hr in [**Hospital Unit Name 153**]). We diuresed him to a goal
of -1-2L on [**8-27**]. Resp status remained stable on NC.
.
# Hypoxemic resp. distress. Likely due to volume overload as
above and possible PNA (treated for CAP, given clinical criteria
w/o CXR changes). Continued CAP tx (ctx and azithro) and
diuresis with a goal of negative 1-2 L/day with good response.
He did have some desats into the low 90s on 5L NC on the morning
of [**9-28**], but by transfer to floor, satting mid 90s on 4-5L NC.
.
# Renal failure. Cr elevated at 1.9 but was stable and this is
his baseline per PCP. [**Name10 (NameIs) **] held lisinopril.
.
# Atrial flutter/fibrillation. Rate controlled. We restared his
digoxin on [**9-27**] and continued his coumadin after his LP, which
was increased to his home dose of 6mg daily on [**9-28**] after INR
became subtherpeutic. Remained in AF.
.
# DM. FS stable throughout admission on Lantus 14U AM and HISS
which pt. self regulates with carb counting
Medications on Admission:
Digoxin 0.25mg daily
Apidra Insulin ss
Glyburide 5mg daily
Lantus 14-16U in AM
Lisinopril 5mg daily
Simvastatin 20mg daily
Vit D 1000U daily
Coumadin 5mg daily.
Discharge Medications:
1. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gm Intravenous Q24H (every 24 hours) for 4 doses.
Disp:*4 gm* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and prn as needed for line flush.
Disp:*10 ML(s)* Refills:*0*
3. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous once a day.
Disp:*480 units* Refills:*2*
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
5. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*20 Tablet(s)* Refills:*0*
6. Insulin Lispro 100 unit/mL Solution Sig: 10-20 units
Subcutaneous four times a day as needed for hyperglycemia: using
the sliding scale and carb counting you have used previously at
home.
Disp:*500 ml* Refills:*0*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sepsis - resolved
Community-acquired pneumonia
Type II diabetes mellitus with complications, controlled
Chronic kidney disease Stage II
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were diagnosed with sepsis from community-acquired
pneumonia. The infection is improved but you should finish the
full 10 day course of IV antibiotics. Your diabetes is now well
controlled on your home insulin regimen. You received a great
deal of IV fluids as part of the treatment for sepsis and you
still have a great deal of fluid swelling in your body for which
you were started on a diuretic. You will probably only need to
take the diuretic until the swelling resolves, after which you
can stop it. The diuretic (furosemide) can cause your blood
potassium level to drop ( dangerous condition), so you need to
have your blood levels checked periodically and followe by your
primary care doctor.
Followup Instructions:
Name: [**Last Name (LF) 639**],[**First Name3 (LF) **] V.
Address: [**Location (un) 96153**], E23-281, [**Hospital1 **],[**Numeric Identifier 26661**]
Phone: [**Telephone/Fax (1) 96154**]
Appt: [**10-5**] at 11:30am
ICD9 Codes: 0389, 486, 5849, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4711
} | Medical Text: Admission Date: [**2105-3-4**] Discharge Date: [**2105-3-8**]
Date of Birth: [**2040-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath and chest discomfort
Major Surgical or Invasive Procedure:
[**2105-3-4**] Coronary artery bypass graft x3 (left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal artery and posterior descending
artery).
History of Present Illness:
64 year old male who has been experiencing exertional chest
tightness and shortness of breath with heavy exertion. He states
he exercises 4-5 times per week on a treadmill. He reports
pressure across his mid chest after 2-3 minutes of exercise. He
belches and the discomfort resolves and he is able to continue
another 20-25 minutes without any symptoms at all. An ETT on
[**2105-2-4**] demonstrated 2 mm of downsloping ST segment depressions
in V5 and V6. Nuclear imaging (per Dr[**Name (NI) 30753**] note [**2105-2-24**])
revealed a large area of ischemia involving the inferior and
lateral walls and no infarction. EF was 60%. He was referred for
a cardiac catheterization and was found to have coronary artery
disease and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Duodenal ulcer
GERD
Seasonal allergic rhinitis
General anxiety disorder
Tonsillectomy
Nasal septoplasty
Skin cancer lesion removed x2
Social History:
Race:Caucasian
Last Dental Exam:every 6 months, going [**2105-2-27**]
Lives with:Alone, widowed
Contact:[**Name (NI) **] (son) Phone# [**Telephone/Fax (1) 92129**]
Occupation:Owner of used auto parts/salvage company
Cigarettes: Smoked no [] yes [x] Hx:quit at the age of 28 and
smoked for 12 years
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-24**] drinks/week [x] >8 drinks/week []
Illicit drug use: denies
Family History:
Premature coronary artery disease- Father died at age 45 from
heart attack
Physical Exam:
Pulse:74 Resp:13 O2 sat:97/RA
B/P Right:136/68 Left:140/72
Height:5'6" Weight:168 lbs
General:
Skin: Dry [x] intact [x] macular rash on chest
HEENT: PERRLA [x] EOMI [x] Glasses/ Teeth in good repair
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x] Concave sternum
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:TR band Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2105-3-4**] Echo: The left atrium is normal in size. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic root. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Post Bypass: The patient is now s/p CABGX4 on a neosynephrine
drip. LV function is now >55%. Mitral regurgitation is
unchanged. Aortal is intact post deccanulation.
[**2105-3-6**] WBC-11.8* RBC-3.42* Hgb-10.4* Hct-30.3 Plt Ct-192
[**2105-3-4**] WBC-17.5*# RBC-3.52* Hgb-10.6* Hct-30.6 Plt Ct-211
[**2105-3-6**] Glucose-121* UreaN-12 Creat-0.9 Na-135 K-4.9 Cl-100
HCO3-28
[**2105-3-4**] UreaN-13 Creat-0.7 Na-140 K-4.1 Cl-113* HCO3-24
[**2105-3-6**] Mg-2.0
[**2105-3-4**] MRSA SCREEN (Final [**2105-3-7**]): No MRSA isolated.
[**2105-3-8**] 04:55AM BLOOD WBC-8.4 RBC-3.13* Hgb-9.4* Hct-26.9*
MCV-86 MCH-30.0 MCHC-34.9 RDW-13.1 Plt Ct-248
[**2105-3-8**] 04:55AM BLOOD Plt Ct-248
[**2105-3-8**] 04:55AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2105-3-8**] 04:55AM BLOOD Mg-2.3
CXR [**3-8**]:
FINDINGS: In comparison with the study of [**3-6**], the patient has
taken a much
better inspiration. There is still substantial enlargement of
the cardiac
silhouette with evidence of pulmonary vascular congestion. Mild
atelectatic
changes are seen at the bases. The small left apical
pneumothorax is stable.
Of incidental note are apparent calcifications in the region of
the carotid
bifurcation on the right.
.
Brief Hospital Course:
Mr. [**Known lastname 15655**] was a same day admit and on [**3-4**] was brought
directly to the operating room where he underwent a coronary
artery bypass graft x 3. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Several hours
later he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was transferred to the
step-down floor for further care. He was gently diuresed towards
his pre-op weight. Chest tubes and epicardial pacing wires were
removed per protocol.
He was followed by physical theapy. Continued to make steady
progress and was discharged to home with VNA on POD #4.
Discharge instructions reviewed and all questions addressed.
Follow-up appointment arranged.
Medications on Admission:
ATORVASTATIN 10 mg Daily
METOPROLOL SUCCINATE 25 mg Daily
MOM[**Name (NI) **] [NASONEX] 50 mcg Spray, 1 spray [**Hospital1 **]
NIFEDIPINE 30 mg Daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual as directed
OMEPRAZOLE 20 mg [**Hospital1 **]
ASPIRIN 81 mg Daily
CENTRUM 1 tablet daily
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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. 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*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Multi-Vitamin HP/Minerals Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Duodenal ulcer
GERD
Seasonal allergic rhinitis
General anxiety disorder
s/p Tonsillectomy
s/p Nasal septoplasty
s/p Skin cancer lesion removed x2
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema absent
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
Wound Check, [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] [**2105-3-17**] at
10:30a [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] in the [**Hospital Unit Name **] [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **] [**2105-3-31**] at 2:00p
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] [**2105-3-20**] at 4:40pm
Please call to schedule appointments with your:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**4-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2105-3-8**]
ICD9 Codes: 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4712
} | Medical Text: Admission Date: [**2175-1-30**] Discharge Date: [**2175-2-2**]
Service: CICU
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
female with a past medical history of hypertension,
hyperlipidemia, and a remote smoking history who presented to
[**Hospital **] Hospital with angina, shortness of breath, and
inferior ST segment elevations on electrocardiogram on
[**2175-1-21**].
Per the patient's son and daughter-in-law, the patient had
been using sublingual nitroglycerin for three weeks prior to
this admission and was not telling anyone. She has had a
history of angina with uncertain workup, but no
catheterizations previous to this admission.
The patient had severe chest pain and shortness of breath on
[**1-21**]. She called an ambulance and was transported to
[**Hospital **] Hospital. There, she refused cardiac catheterization
and lytics were not given. The patient's initial troponin I
was 55.5 on [**1-21**] with a creatine kinase of 2300 (that
peaked on [**1-21**]). She was managed medically with
heparin, aspirin, Plavix, nitroglycerin, Lopressor, and
captopril. Her chest x-ray showed pulmonary edema. She was
given Lasix as needed.
An echocardiogram on [**1-24**] at [**Hospital **] Hospital
demonstrated an ejection fraction of 30%, inferior akinesis,
and 3+ mitral regurgitation. The patient was also diagnosed
with Klebsiella and Escherichia coli urinary tract infection.
The patient was transferred to [**Hospital1 188**] for cardiac catheterization.
Admission catheterization revealed 3-vessel disease. The
patient's left coronary artery was very short and heavily
calcified. The left anterior descending artery with a 90%
ostial lesion with evident ulceration. The left circumflex
was a nondominant vessel with mid segment 90% lesion. The
right coronary artery dominant with occlusion proximally and
distal flow from left-to-right collaterals. Right atrial
pressure was 12. The pulmonary artery pressure was 60/30.
Pulmonary capillary wedge pressure was 35. Cardiac output
was 4.4. Cardiac index was 2.8.
Status post cardiac catheterization, in the holding area, the
patient went into rapid atrial fibrillation and was given
intravenous Lopressor. Her heart rate went from 180 to 110s.
Her blood pressure remained stable.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Angina.
2. Dementia.
3. Thyroid disease.
4. Glaucoma.
5. Cataracts.
6. Grave's disease.
7. Hypercholesterolemia.
8. Hypertension.
SOCIAL HISTORY: The patient lives alone. She was previously
employed as an English teacher. She graduated from [**University/College 52463**]. She quit smoking 40 years prior.
CODE STATUS: Code status is do not resuscitate/do not
intubate (per the patient's son who is her health care
proxy). The patient's son is [**Name (NI) **] [**Name (NI) 8163**] (telephone
number [**Telephone/Fax (1) 52464**]).
MEDICATIONS ON ADMISSION: (On transfer medications were)
1. Aspirin 325 mg by mouth once per day.
2. Captopril 12.5 mg by mouth three times per day
3. Plavix 75 mg by mouth once per day.
4. Imdur 60 mg by mouth once per day.
5. Levoxyl 100 mcg by mouth once per day.
6. Lopressor 25 mg by mouth twice per day.
7. Zocor 10 mg by mouth once per day.
8. Risperidone.
9. Aricept.
10. Colace.
11. Levaquin 250 mg (times two days).
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed the patient's temperature was 97.7, her
heart rate was irregular at 90 to 120, her blood pressure was
97/59, and her oxygen saturation was 98% on 2 liters nasal
cannula. Physical examination was notable for increased
jugular venous pressure. There were crackles bilaterally at
the bases on pulmonary examination. The patient was alert
and oriented times three, but varied depending on when she
was asked. She was not always alert and oriented. The
patient had an irregular rhythm. First heart sounds and
second heart sounds were normal. No third heart sound. No
fourth heart sound. The patient had a [**1-13**] holosystolic
murmur at the apex. The patient had 2+ pulses throughout.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on [**1-22**] revealed an inferior ST elevations, and large Q waves.
An echocardiogram on [**2175-1-14**] revealed an ejection
fraction of 30%, 3+ mitral regurgitation, left ventricular
lateral wall akinesis, mid distal posterior wall akinesis,
mid distal inferior wall akinesis, and distal anterior wall
akinesis.
PERTINENT LABORATORY VALUES ON PRESENTATION: Creatine kinase
values from the outside hospital on [**1-21**] was 234 which
peaked on [**1-21**] at 2324 and trended back down and was
140 on admission. Troponin I was initially 1.04 and peaked
at 55.5 and was 3.09 on admission to [**Hospital1 190**]. Sodium was notable for being 129 on
admission. The patient's admission hematocrit was 27.8.
Urine culture was notable for Escherichia coli and Klebsiella
on [**1-27**] (from the outside hospital). The patient's
thyroid-stimulating hormone on [**1-23**] was 0.54. Her
cholesterol was 142, her triglycerides were 112, her
high-density lipoprotein was 47, and her low-density
lipoprotein was 73.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is an 89-year-old female with cardiac risk factors of
hypertension, high cholesterol, and previous smoking who
presented to an outside hospital with acute ST-elevation
inferior myocardial infarction. She was managed medically,
per patient wishes. The patient presents now with
compromises left ventricular function, status post resolution
of her myocardial infarction. Ejection fraction on admission
documented an outside hospital was 30% with areas of akinesis
and hypokinesis of the left ventricle.
Cardiac catheterization demonstrated severe 3-vessel disease
and elevated filling pressures with moderate-to-severe mitral
regurgitation. The catheterization was complicated by atrial
fibrillation with a rapid ventricular rate with some response
to intravenous Lopressor. The patient was not a candidate
for coronary artery bypass graft. Per her son, her health
care proxy, the patient would never want this; which was
reasonable from a medical standpoint. No intervention or
percutaneous transluminal coronary angioplasty, as the
patient was unlikely to be without complications. The
decision was made to pursue medical management.
1. CARDIOVASCULAR ISSUES: (a) CORONARY ARTERY DISEASE
ISSUES: The patient was maintained on her aspirin, Plavix,
and heparin once her sheath was pulled. She was maintained
on a statin. The patient underwent no intervention during
this hospitalization. An ACE inhibitor and beta blocker were
added to her regimen as her blood pressure were tolerate over
the course of her hospital stay and titrated. The patient
was able to ambulate without anginal symptoms prior to her
discharge to a rehabilitation facility.
(b) RHYTHM: The patient was in rapid atrial fibrillation
with some response to intravenous Lopressor. The patient was
started on an intravenous amiodarone load which was changed
to an oral load. Her thyroid function tests and liver
function tests were monitored. Pulmonary function tests were
to be obtained as an outpatient should the patient stay on
amiodarone. The patient converted to a normal sinus rhythm
and remained in a normal sinus rhythm with no atrial
fibrillation times two days. Amiodarone was discontinued, as
it was thought that the patient's atrial fibrillation was
related to her catheterization only. The patient was
monitored and found to be in a normal sinus rhythm prior to
her discharge.
2. CONGESTIVE HEART FAILURE ISSUES: The patient was noted
to be volume overloaded and was diuresed throughout this
admission. The patient will require further diuresis at her
rehabilitation facility based on a clinical daily
examination. The patient responded well to 40 mg of
intravenous Lasix corresponding to 80 mg by mouth of Lasix.
The patient was monitored initially with a Swan-Ganz catheter
times two days. This was removed without complications. A
beta blocker and ACE inhibitor were restarted without
complications.
3. ANEMIA ISSUES: The patient was admitted initially with a
hematocrit of 27.8. The patient was transfused one unit or
packed red blood cells. Her hematocrit responded
appropriately and remained at 30 throughout the remainder of
the [**Hospital 228**] hospital course.
4. URINARY TRACT INFECTION ISSUES: The patient was admitted
with an Escherichia coli and Klebsiella urinary tract
infection. Her urinalysis was rechecked after three days on
levofloxacin and found to still be consistent with a urinary
tract infection. The patient was to be continued for a full
course of levofloxacin.
5. DEMENTIA ISSUES: The patient has underlying low-grade
dementia. She was maintained on her Aricept and risperidone.
6. HYPOTHYROIDISM ISSUES: The patient was maintained on her
Synthroid.
7. CODE STATUS ISSUES: The patient is confirmed do not
resuscitate/do not intubate.
FINAL DISCHARGE DIAGNOSES:
1. Inferior myocardial infarction.
2. Hypertension.
3. Coronary artery disease.
4. Angina.
5. Dyspnea.
6. Urinary tract infection (Klebsiella and Escherichia
coli).
7. Hypothyroidism.
8. Dementia.
MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: Cardiac
catheterization on [**2175-1-30**].
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient had an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
[**2175-3-9**] at 1 p.m. at the [**Last Name (un) 469**] Building, seventh
floor.
2. The patient was instructed to follow up with her primary
care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) within the next few weeks
(telephone number [**Telephone/Fax (1) 44655**]).
3. The patient was instructed to follow up with medical
director of the [**Hospital 228**] rehabilitation facility.
4. The patient will need daily clinical evaluation for
pulmonary edema and volume overload, and a dose of Lasix on
an as needed basis.
5. The patient will require Physical Therapy and
Occupational Therapy for cardiac rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Acetaminophen.
2. Aspirin 325 mg by mouth once per day.
3. Levothyroxine 100 mcg by mouth every day.
4. Plavix 75 mg by mouth once per day.
5. Simvastatin 10 mg by mouth once per day.
6. Donepezil 5 mg by mouth once per day.
7. Risperidone 1 mg by mouth once per day.
8. .................... 40 mg by mouth once per day.
9. Docusate 100 mg by mouth twice per day.
10. Senna.
11. Bisacodyl.
12. Levofloxacin 250 mg once per day (times five days).
13. Toprol-XL 50 mg by mouth once per day.
14. Lisinopril 5-mg tablets take 0.5 tablet by mouth once
per day.
15. Lasix 40 intravenously or 80 mg by mouth as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 5713**]
MEDQUIST36
D: [**2175-2-2**] 14:16
T: [**2175-2-2**] 16:53
JOB#: [**Job Number 52465**]
ICD9 Codes: 4280, 4240, 5990, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4713
} | Medical Text: Admission Date: [**2118-12-16**] Discharge Date: [**2118-12-17**]
Service: MEDICINE
Allergies:
Codeine / Percocet / Ambien
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname **] is an 84 year old male with history of CAD and CHF
with multiple recent admits ([**Date range (1) 24293**], [**Date range (1) 24294**], [**Date range (1) 24295**])
for MRSA pneumonia who presents with dyspnea. Per records, he
had increasing sob and lower extremity edema over the past two
days. He also c/o CP after moving bowels.
.
Patient initially presented to [**Hospital1 18**] on [**11-10**] with complaints of
SOB. He was diagnosed with a MRSA pneumonia and treated with
Vancomycin and Levaquin for a total of 14 and 10 days each.
During that admission, he had a left mainstem bronchus plugging
with left lung collapse requiring bronchoscopy [**11-14**] (cx grew
MRSA).
Large left pleural effusion tapped [**11-17**] (1.4L, transudate, cx
negative). Most recent admission from [**Date range (1) 24295**]) when patient
admitted with dyspnea. Treated with Vanc/zosyn for PNA, and
diuresed.
.
In the ED, 98.4, HR 1020 BP 110/70 95%RA. c/o sob and placed on
CPAP and nitro gtt and transferred to the ICU. He received 325
ASA, Lasix 40 X 2, Morphine 2mg and albuterol/ipratrop nebs.
.
On arrival to the ICU, he is on bipap. he states breathing is
improved. Denies any chest pain. denies recent fevers, chills,
n,v.
Past Medical History:
- CAD s/p (LIMA to LAD, SVG to OM2, SVG to RCA), repeat CABG
[**2105**] after LIMA found to be occluded (Y-graft SVG to first acute
marginal and LAD)
- HTN
- dyslipidemia
- SSS s/p pacemaker [**7-27**]
- CHF - EF 40% 10/06
- Gout
- OA
- h/o GIB
- s/p knee replacements
- s/p CCY
- s/p prostate surgery
- ?atrophic kidney
Social History:
Had lived with his wife. Denies [**Name2 (NI) **]/tob/drugs. Came from [**Hospital1 1501**]
after recent admission
Family History:
NC
Physical Exam:
VITALS: 96.2, HR 99, BP 121/76 RR 26 O2 100%
Gen: Elderly male with FM on in nad.
HEENT: MMM, OP clear
Neck: supple, no carotid bruits, difficult to assess JVP.
Lungs: Bilateral wheezing.
CV: RRR, nl S1S2, no m/r/g
Abd: Soft, obese
Ext: 2+ edema upto thighs, acebandage below the knees.
Neuro: AAOx3, no focal deficits
Brief Hospital Course:
Impression and plan: 84 yom with h/o CAD, CHF and MRSA PNA
admitted with dyspnea. Unclear precipitant but patient with
worsening volume overload over the past two days including
dyspnea and lower extremity edema.
.
# Respiratory distress - Likely multifactorial given h/o MRSA
PNA and CHF. CHF likely contributing to the majority of dyspnea
especially given wt gain over the past few days and CXR with
worsening Pulmonary edema. Pt was initially intubated because
the family felt it might ease his suffering. The pt
self-extubated but was reintubated by anaesthesia.
Hypotension- During his initial hours in the ICU, the pt's
systolic blood pressure decreased to the low 70's. He was
started on phenylepherine to raise his blood pressure.
We discussed his course and previously stated wishes with his
family, who asked that the patient be made comfort measures
only. His family asked that no additional changes to the
patient's medication regimen. The patient's blood pressure fell
in the evening and his hear rate did not respond. The patient
was pronounced at 931pm
Medications on Admission:
Ipratropium Bromide q6h.
Calcium Carbonate 500 mg Tablet, tid
Cholecalciferol (Vitamin D3) 400 unit [**Unit Number **] tab [**Hospital1 **]
Ferrous Sulfate 325 (65) mg Tablet Oncea day
Atorvastatin 20 mg Tablet once a day.
Aspirin 325 mg Tablet, once a day
Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL Injection
QMOWEFR (Monday -Wednesday-Friday).
Dolasetron 12.5 mg q8 prn
Docusate Sodium 100 mg po bid
Metoprolol Tartrate 12.5 po bid.
Hydralazine 10 mg po q6h.
Simethicone 80 mg Tablet po qid prn.
Aluminum-Magnesium Hydroxide qid prn.
Furosemide 40 mg Tablet PO BID
Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Hospital1 **] prn for pain.
Isosorbide Dinitrate 10 mg TID
Bismuth Subg-Balsam-ZnOx-Resor
Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q48H (every 48 hours) until [**12-21**]
Unasyn 1.5gm tid until [**12-21**]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
heart failure, systolic exacerbation
hypotension
pneumonia, Staphylococcal
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 4280, 5859, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4714
} | Medical Text: Admission Date: [**2153-8-30**] Discharge Date: [**2153-8-31**]
Date of Birth: [**2077-7-1**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Coumadin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
Stitches placed for head laceration
History of Present Illness:
Mr [**Known lastname 24110**] is a 76yo man with stable multiple sclerosis with
chronic suprapubic cath, hx prostate ca, left parietal AVM, PAF
who presents s/p mechanical fall. He insists he caught his
[**Known lastname **] wheel and fell, no syncope or dizziness, no LOC. His wife
heard him call that he was about to fall, and saw him
immediately afterward. EMS noted him to be bradycardic in
field.
Head lac after he hit his right brow on wall; lac repaired in
ED.
He insists his heart rate is typically in 40s-50s; his
cardiologist has not suggested intervention. He has not had a
fall in years despite MS, left leg [**Last Name (LF) 36579**], [**First Name3 (LF) **] use. He
mentions his blood pressure is typically in the 130s but
routinely falls to 110s if he doesn't drink much during the day.
No chest pain, lightheadedness, change in urine, cough,
dyspnea, fever, night sweats or chills.
He was recently admitted for an acute change in mental status
and bradycardia.
In the ED, HR dipped temporarily to 34, mostly around 50. SBPs
were in 90s/100s. He was afebrile w/O2 sat 100% on RA. CT head
and c-spine were negative. A U/A showed 30-50WBCs, moderate
bacteria and 0-2 epithelial cells. He was feeling well and not
pleased he was to be admitted. He was admitted to the MICU
On the floor, patient was bradycardic (50s), and borderline
hypotensive (in 90's systolic).
Past Medical History:
1. Multiple sclerosis - followed by Dr.[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 45435**] at [**Hospital1 2025**].
2. Neurogenic bladder - suprapubic catheter in place; followed
by Dr. [**Last Name (STitle) 9125**].
3. Hypertension
4. Severe constipation - followed by Dr. [**Last Name (STitle) 10689**].
5. Glaucoma
6. Prostate cancer - s/p hormonal therapy and radiation. He has
been pursuing watchful waiting since the Spring [**2149**]. He is
followed at the [**Hospital3 328**] Cancer Institute.
7. Pneumonia
8. Cellulitis
9. Osteoarthritis
10. Hyperlipidemia
11. Depression
12. History of AVM in the left parietal lobe
13. Obstructive sleep apnea utilizing CPAP at night
14. Peripheral neuropathy
15. Thoracic outlet syndrome
16. PE - [**3-21**]
17. Gastroesophageal reflux disease
18. History of MRSA
19. History of left foot fracture
21. Osteopenia
22. Atrial Fibrillation on [**Month/Year (2) **]
22. Shingles - [**2151**]
Social History:
Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via
AA. Quit cigars a few years ago. Retired judge (at age 68 due to
fatigue).
Family History:
Per notes, daughter and cousin with MS, mother with AD, father
with leukemia, brother with arrhythmia.
Physical Exam:
Vitals: T: 95.4 axillary BP: 108/52 P:43 R:14 O2: 100% RA
General: Alert, oriented, no acute distress, pleasant
HEENT: Laceration above right eye, dressing c/d/i. Some dried
blood around right eye. Vision loss, old, in right eye.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Heart sounds are distant, 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 suprapubic tenderness.
GU: no foley
Ext: warm, well perfused, 2+ pulses throughout, no edema
Pertinent Results:
ADMISSION LABS:
[**2153-8-30**] 07:00PM BLOOD WBC-5.9 RBC-3.52* Hgb-10.6* Hct-31.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-14.3 Plt Ct-186
[**2153-8-30**] 07:00PM BLOOD Neuts-62.3 Lymphs-25.6 Monos-5.7 Eos-5.6*
Baso-0.8
[**2153-8-30**] 07:00PM BLOOD PT-12.7 PTT-29.4 INR(PT)-1.1
[**2153-8-30**] 07:00PM BLOOD Glucose-122* UreaN-25* Creat-1.3* Na-139
K-4.6 Cl-106 HCO3-27 AnGap-11
[**2153-8-30**] 07:00PM BLOOD cTropnT-<0.01
UA:
[**2153-8-30**] 07:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2153-8-30**] 07:00PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2153-8-30**] 07:00PM URINE RBC-0 WBC-21-50* Bacteri-MOD Yeast-NONE
Epi-0-2
[**2153-8-30**] 10:41PM URINE Hours-RANDOM UreaN-473 Creat-72 Na-49
K-62 Cl-62
[**2153-8-30**] 10:41PM URINE Osmolal-400
CE trend:
[**2153-8-30**] 07:00PM BLOOD cTropnT-<0.01
[**2153-8-31**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01
MICRO:
[**8-30**] UCx: pending
IMAGING:
[**8-30**] CT Cspine:
1. No evidence of acute injury to the cervical spine.
2. Left thyroid nodules. Followup with ultrasound is suggested
if previously not evaluated.
[**8-30**] CT head:
No evidence of acute intracranial abnormality. Stable, likely
cavernoma within the left parietal lobe and likely colloid cyst
in the third ventricle. No hydrocephalus.
DISCHARGE LABS:
[**2153-8-31**] 05:10AM BLOOD WBC-6.5 RBC-2.97* Hgb-9.1* Hct-26.9*
MCV-91 MCH-30.7 MCHC-33.9 RDW-14.4 Plt Ct-147*
[**2153-8-31**] 05:10AM BLOOD Glucose-123* UreaN-26* Creat-1.1 Na-144
K-3.8 Cl-111* HCO3-26 AnGap-11
[**2153-8-31**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2153-8-31**] 05:10AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2
[**2153-8-30**] 07:00PM BLOOD TSH-0.91
Brief Hospital Course:
Mr. [**Known lastname 24110**] is a 76 year old male with MS, h/o sinus bradycardia
and recent admission for vasovagal syncope who prsents s/p
mechanical fall, found to be hypotensive and bradycardic.
#. Hypotension/Hypertension - Pt with very labile blood
pressures ranging from SBP 90s-low 200s, likely [**12-19**] to autonomic
dysfunction. Pt admitted with SBP 90s, initially improved with
small bolus of IVF. Prior to discharge, the patient was noted to
be hypertensive (up to SBP 208). He was continued on his home
Enalapril at discharge, but this should be discussed at his
upcoming outpatient appointments with his cardiolgist and
gerontologist, as the episodes of hypotension may be
contributing to his instability and falls.
#Falls - Pt evaluated by PT who determined that from a
mechanical state, the pt is a high risk for falling again. PT
arranged for home PT sessions.
# Bradycardia - Pt with sinus bradycardia, similar to recent
[**Month/Day (2) 5348**]. EKG with prolonged PR interval. TSH was WNL. Pt has
f/u with cardiology in 3 days.
# ARF: Likely pre-renal, as FENa was <1%. Cr improved with IVF.
# Head Lac - Was sutured in ED with absorbable sutures (no need
to remove), CT of head/Cspine showed no acute process (no
bleed). CT Cspine does note thyroid nodules, which should be
followed up with ultrasound if not previously worked up.
- needs thyroid ultrasound
# Multiple Sclerosis: Walks with a [**Month/Day (2) **] at [**Month/Day (2) 5348**]
# UTI: Likely colonized given chronic suprapubic catheter. No
fever, elevated WBC count, or elevated lactate. Pt received a
dose of Ceftriaxone in the ED, but further antibiotics were
held.
- f/u UCx
#OSA: Bipap while inpatient
#Glaucoma: Continued home eye drops
#Multiple sclerosis: Has been stable for many years. Ambulates
w/[**Month/Day (2) **]. Evaluted by physical therapy - the patient is quite
unstable and at high risk for further falls. He is not agreeable
to going to rehab at this time.
#HLD: Continued home simvastatin
#Afib: Continued home [**Last Name (LF) 4532**], [**First Name3 (LF) **]
Medications on Admission:
1. BACLOFEN - 20 mg Tablet - 2 Tablet(s) by mouth at bedtime
Patient
is taking variable dose.
2. BRIMONIDINE-TIMOLOL [COMBIGAN] - 0.2 %-0.5 % Drops - 1
drop(s)
both eyes twice a day Dispense 4 bottles
3. CLOPIDOGREL [[**First Name3 (LF) **]] - 75 mg Tablet - 1 Tablet(s) by mouth
daily
- No Substitution
4.DARIFENACIN [ENABLEX] - (Prescribed by Other Provider) - 7.5
mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily
5. DORZOLAMIDE - 2 % Drops - 1 drop(s) both eyes three times a
day
Dispense 90 days
6. ENALAPRIL MALEATE [VASOTEC] - (Prescribed by Other Provider)
-
10 mg Tablet - 1 Tablet(s) by mouth daily
7. EXCEDRIN - (Prescribed by Other Provider) - Dosage uncertain
8. LATANOPROST [XALATAN] - 0.005 % Drops - 1 drop(s) both eyes
at
bedtime Dispense 90 days
9. NITROFURANTOIN (MACROCRYST25%) [MACROBID] - 100 mg Capsule -
1
Capsule(s) by mouth daily Taking for one out of three weeks in
antibiotic cycle.
10. OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2
Capsule(s)
by mouth twice a day
11. SIMVASTATIN [ZOCOR] - 10 mg Tablet - 1 Tablet(s) by mouth at
bedtime
12. Gabapentin 800mg PRN
13. ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
14. CALCIUM 600 + D - 600 mg (1,500 mg)-200 unit Tablet - 1
Tablet(s)
by mouth three time daily Take with meals
15. CASCARA SAGRADA - (Prescribed by Other Provider) - Dosage
uncertain
16. DOCUSATE SODIUM [COLACE] - (OTC) - 100 mg Capsule - 2
Capsule(s)
by mouth once a day
17. MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. baclofen 20 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Calcium 600 + D(3) 600-200 mg-unit Capsule Sig: One (1)
Capsule PO three times a day: with meals.
10. cascara sagrada 450 mg Capsule Sig: as previously prescribed
Capsule PO as previously prescribed.
11. Colace 100 mg Capsule Sig: Two (2) Capsule PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Combigan 0.2-0.5 % Drops Sig: One (1) drop, both eyes
Ophthalmic twice a day.
14. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Mechanical fall
Head laceration
Acute renal failure
Bradycardia
Hypotension
Secondary Diagnosis:
Atrial fibrillation
Multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ([**Hospital **]
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 24110**],
You were admitted to the hospital after a fall. You had stitches
placed in your forehead for a laceration. These stitches will
resorb on their own and do not need to be removed. Your heart
rate and blood pressure were noted to be low, which improved
with intravenous fluids. You were also noted to have mild renal
failure, which also improved with intravenous fluids. Prior to
discharge, your blood pressure was noted to be quite high while
you were walking with physical therapy. You should continue on
your blood pressure [**Known lastname 4085**] as previously prescribed - but
please ask your doctors about this [**Name5 (PTitle) 4085**] during your
scheduled follow up appointments, as your blood pressure ranged
from systolics of 90s-200s.
No changes were made to your medications.
We recommend that you spend the next few days resting at home.
You just had a fall, and your heart rate and blood pressure were
quite low - concerning enough to be admitted to the intensive
care unit. You will likely improve faster if you stay home and
reduce your physical activity over the next 2-3 days. It will
also be very important for you to work with physical therapy at
home to improve your strength. You are at a very high risk of
falls, which can be very dangerous.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with the following providers:
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Date: Monday [**2153-9-3**]
Gerontology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**]
Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2153-9-5**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2153-9-12**] 3:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4715
} | Medical Text: Admission Date: [**2118-11-18**] Discharge Date: [**2118-11-21**]
Service: MEDICINE
Allergies:
Haldol / Benadryl
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 yo F with HTN, CAD s/p MI with LAD/RCA stents in [**2112**], DM2 on
insulin, PVD, CKD (baseline Cr 5.5), and dementia (?nonverbal at
baseline) admitted from ED with SOB and worsening mental status
x3 weeks. The patient was originally hospitalized at [**Location (un) **]
from [**2118-9-26**] to [**2118-10-14**] with left purulent foot ulcer s/p
debridement. She was then transferred from the rehab facility
with SOB and tachypnea back to [**Location (un) **] and from there to [**Hospital1 18**]
ED for further management. At [**Location (un) **] she received Lasix 80 mg
IV x1 and placed on CPAP with improvement in her respiratory
status. Initial vitals at [**Location (un) **] were HR 86, RR 28, 100% on
Neb, BP 137/72. ABG 7.27/40/68/18. WBC 21.4, HCt 31.6, K 6.3,
Bicarb 19, BUN 108, Creat 5.1. BNP 1332. She was transferred to
[**Hospital1 18**] for further management.
On arrival to our ED, she was transitioned from CPAP with O2 sat
of 90% to a NRB with O2 sat 94-98%. T 99.8, BP 187/63, HR 98, RR
30. She received 500 cc NS bolus, levoflox, anzemet, hydral, and
isordil. Her WBC count was noted to be 23 with no bands, lactate
of 1.6. UA with >50 WBC's and few bacteria. BNP [**Numeric Identifier **]. CXR/Chest
CT revealed moderate congestive heart failure. A Right IJ was
placed. Cr noted to be 5.3 (at baseline). ECG revealed slight ST
depression in V4-V6, Trop of 0.31 (in the setting of Cr of 5.3)
with a negative MB. She was transferred to [**Hospital Unit Name 153**] for diuresis.
Recently admitted to [**Location (un) **] on [**2118-9-26**] until [**2118-10-14**] with
left foot ulcer draining puss s/p debridement. On [**11-13**] Na 136,
K 3.3, Cl 110. Bicarb 18, BUN 99, Creat 5.5; reported to be
baseline. Baseline Hct 37. Echo with well preserved EF, no
valvular abnormality.
Pt is currently nonverbal and is unable to give any further
history.
Past Medical History:
- CAD s/p anterior MI [**2112**], s/p stent in LAD and RCA in [**Country **]
[**Country **]. Repeat cardiac catheterization [**2112**] at [**Hospital1 18**] revealed 1.
Two vessel coronary artery disease. 2. Normal ventricular
function. 3. Patent stents in the LAD and RCA
- DM 2: on Insulin, c/b neuropathy
- CKD (baseline Cr of 5.3)
- Peripheral vascular disease with ulcerations
- Anemia (baseline HCT ~30 from [**2113**])
- Hypertension
- Hypothyroidism
- h/o MRSA of right foot s/p partial amputation
- h/o C-diff [**12/2112**]
- paroxysmal Afib on dig (now in sinus), ?coumadin
- h/o GI Bleed
Social History:
The patient is a Spanish-speaking female who lived at [**Location (un) 931**]
House Nursing Home, before going to rehab. Denies Tob, EtOH, or
illicit drug use. Her son is a physician at [**Name (NI) **] Hospital.
Family History:
+ DM
Physical Exam:
Tm 99.8 ax BP 161/55 HR 103 RR 25 Sat 97% 2 L NC
Gen: Elderly female in NAD. Groaning but nonverbal. Resting
in bed.
HENNT: NC AT. Dry mucous membranes.
CV: RRR. S1S2. No M/R/G.
Lungs: CTA anteriorly and laterally.
Abd: Soft. ND. Does not appear tender. Positive bowel sounds.
Guaiac negative as per ED note. PEG site clean.
Ext: No c/c/e. S/P right great toe amputation. Extensive
ulceration and necrosis of left foot to level of the bone. Most
of heal area has been completely debrided.
Neuro: Nonverbal. Not following commands.
Pertinent Results:
[**2118-11-18**] 01:15AM BLOOD WBC-23.0*# RBC-3.53* Hgb-9.6* Hct-29.8*
MCV-85 MCH-27.1 MCHC-32.1 RDW-18.2* Plt Ct-355
[**2118-11-18**] 01:15AM BLOOD Neuts-88.7* Bands-0 Lymphs-7.7* Monos-3.5
Eos-0 Baso-0.1
[**2118-11-18**] 01:15AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL
[**2118-11-18**] 01:15AM BLOOD Plt Smr-NORMAL Plt Ct-355
[**2118-11-18**] 01:15AM BLOOD PT-13.1 PTT-25.9 INR(PT)-1.2
[**2118-11-18**] 01:15AM BLOOD Glucose-137* UreaN-116* Creat-5.3*#
Na-144 K-5.9* Cl-109* HCO3-16* AnGap-25
[**2118-11-18**] 04:33PM BLOOD ALT-16 AST-12 LD(LDH)-348* CK(CPK)-59
AlkPhos-199* TotBili-0.3
[**2118-11-18**] 01:15AM BLOOD cTropnT-0.31* proBNP-[**Numeric Identifier 30174**]*
[**2118-11-18**] 04:33PM BLOOD CK-MB-5 cTropnT-0.26*
[**2118-11-18**] 11:00PM BLOOD CK-MB-4 cTropnT-0.28*
[**2118-11-18**] 01:15AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.5
[**2118-11-20**] 06:15AM BLOOD WBC-15.0* RBC-3.51* Hgb-9.3* Hct-29.6*
MCV-84 MCH-26.6* MCHC-31.6 RDW-20.0* Plt Ct-337
[**2118-11-21**] 03:57AM BLOOD WBC-14.5* RBC-3.29* Hgb-8.7* Hct-27.6*
MCV-84 MCH-26.4* MCHC-31.4 RDW-18.2* Plt Ct-298
[**2118-11-19**] 03:45AM BLOOD Neuts-86.3* Bands-0 Lymphs-10.2*
Monos-3.0 Eos-0.2 Baso-0.3
[**2118-11-20**] 06:15AM BLOOD PT-13.3 PTT-26.7 INR(PT)-1.2
[**2118-11-21**] 03:57AM BLOOD Glucose-221* UreaN-110* Creat-5.1*
Na-147* K-3.4 Cl-109* HCO3-25 AnGap-16
[**2118-11-20**] 08:00PM BLOOD Na-150*
[**2118-11-18**] 04:33PM BLOOD ALT-16 AST-12 LD(LDH)-348* CK(CPK)-59
AlkPhos-199* TotBili-0.3
[**2118-11-18**] 11:00PM BLOOD CK(CPK)-55
[**2118-11-21**] 03:57AM BLOOD Vanco-14.6*
[**2118-11-20**] 06:15AM BLOOD Vanco-17.5*
.
CXR [**11-18**]: Interval placement of a right internal jugular
central venous catheter. Unchanged congestive heart failure with
bilateral pleural effusions.
.
CT Chest [**11-18**]: 1. Findings consistent with moderate congestive
heart failure. 2. Right internal jugular central venous catheter
terminating in the right atrium. 3. Atherosclerotic
calcifications seen throughout the aorta and its branches, as
well as coronary arteries.
.
CT Head [**11-18**]: No evidence for hemorrhage or cortical
territorial infarction.
.
ECG: NSR, rate 96, LAD, nl intervals, new 0.[**Street Address(2) 1755**] depression
in V4-V6.
.
CXR [**11-19**]: : 1.Mild congestive heart failure. 2. Improvement in
the left perihilar infiltrate.
.
Art Duplex of LE [**11-18**]: prelim read by vasc surgery - R graft
occluded, L metatarsal PVR 12 mm
.
blood cx [**11-18**]: P
foot cx [**11-18**]: GPC 2 types
urine cx [**11-19**]: P
.
UA: 15 RBCs 9 WBCs few bact 500 prote 100 gluc sm bld tr leuks
.
Brief Hospital Course:
87 yo F with HTN, CAD s/p MI with LAD/RCA stents in [**2112**], DM2 on
insulin, PVD, and dementia (?nonverbal at baseline) transferred
from [**Hospital **] Hospital with SOB from fluid overload and L foot
ulcer.
.
* SOB: The patient's SOB was thought likely to be due to fluid
overload; Chest X-Ray and Chest CT revealed moderate CHF; BNP
[**Numeric Identifier 30174**]. This was most probably from diastolic dysfunction as she
had a normal EF on previous echos. There was no evidence of
infiltrate on CXR or CT. It was unlikely to be a PE as she was
on standing SC heparin. While in house, strict I/Os were
monitored with gentle diuresis with PRN lasix for goal 500cc - 1
L negative per day. Oxygen was given as needed to maintain
saturation of 93% or above. Patient was satting better than 95%
on room air on discharge.
.
*Foot Ulcer: Her left foot ulcer was assessed by vascular
surgery out of the primary team's concern for osteomyelitis.
The wound was debrided by vascular surgery on [**11-18**] and wound
culture was sent. She was placed on vancomycin for empiric
coverage, dosed by levels. Arterial duplex studies were done.
The surgical team recommended amputation before the patient
became septic. No other revascularization was recommended. Her
son felt that amputation was against his mother's wishes, and
opted for conservative management. Her wound was cleaned with
Dakin's solution and dressed with wet to dry dressings [**Hospital1 **]. She
was to complete a six week course of vancomycin (her first dose
here was on [**2118-11-19**]) for her presumed osteomyelitis, although
amputation was considered the best treatment.
.
*UTI: The patient had a UA suspicious of UTI, but epithelial
cells were present. Repeat UA also showed signs of infection.
A urine cx was sent. The patient was continued on levofloxacin
(dosed Q48 hours). She was to complete a 10 day course of
antibiotics and her regimen should end on [**2118-11-28**].
.
*Elevated WBC: The patient had a chronic elevation of her WBC
count (in OMR from yr [**2112**]). There were no signs of sepsis --
the patient remained afebrile, hypertensive, with a normal
lactate. The most probable source of her leukocytosis is osteo
of the left foot with the extensive ulceration and exposed bone.
UTI was also considered as source of infection. Her decreased
mental status was thought to be a combination of infection and
uremia.
.
*CRF: The patient presented with Chronic Renal Failure, with her
creatinine at baseline of 5.3. She continued to make urine.
Her Cr was followed daily; medications were all renally dosed.
She was also continued on epogen. The patient's gap acidosis of
20 was thought to be due to uremia. Bicitra was continued. It
is recommmended that the patient follow-up with the PCP
regarding possible initiation of dialysis.
.
*Hypernatremia: The patient was hypernatremic on presentation.
After her diuresis in the ICU, she was given 1L D5W on the floor
to help correct this. Her free water defecit was calculated to
be 2.6 liters. Her free water flushes via her PEG tube was
increased to 50cc Q2 hours. This may be reduced to 50 cc q
4hours when her hypernatremia resolves.
.
*HTN: The remained hypertensive and tachycardic while
hospitalized. Since there were no signs of sepsis, she was
continued on metoprolol and norvasc. Her metoprolol dosing was
increased to 50 TID for better control.
.
* CAD- s/p MI and stenting in [**2112**]. ECG changes were
nondiagnostic but patient had 0.[**Street Address(2) 1755**] depressions in V4-V6
that were most likely demand-related in the setting of
hypertension. Cycled cardiac enzymes and were flat. She was
started on ASA prior to her d/c. Had been noted to be guiac
negative during admission before this was started.
.
*Type 2 DM- She was continued on NPH at reduced doses (16/8) and
cover with RISS. QID FS. Sugars were elevated in the last few
days of admission, but this was attributed to giving the patient
D5W for her hypernatremia and juice flushes for clogged PEG
tube.
.
*Paroxysmal A.Fib - Patient was in sinus rhythm but on dig.
Digoxin level was supratherapeutic during admission, so dc'd.
She was on Metoprolol TID for rate control. Would recommmend
follow-up with her PCP regarding initiation of anti-coagulation.
.
* FEN: Patient received TF's per G-tube. She had agressive
electrolye replacement. Potassium was followed closely, given
her renal failure. Bicitra was given for low bicarb. PEG had a
history of clogging at [**Location (un) **] and clogged several times her.
Was flushed with cranberry juice, carbonated beverages to
unclog. GI recommmended bicarb to help unclog the tube as well.
.
*PPX: SC heparin, PPI, bowel regimen, aggressive mouth care.
Contact precautions for h/o C.Diff and MRSA.
.
*Communication: Communication was with her son, Dr [**Name (NI) 1692**]
[**Name (NI) 30175**].
.
* Code status: She was maintained as FULL CODE.
.
*Dispo- She was transferred to [**Hospital **] Hospital per her son's
request, since he was on staff there.
Medications on Admission:
- Accuzyme ointment
- Nitro ointment 2% 2inches q 6 hrs
- Epo 20,000 3x/week
- levoxyl 0.125 daily
- phoslo 667 tid
- dig 0.125 QOD
- Hep SC BID
- Metop 25 [**Hospital1 **]
- Pantroprazole 40 IV daily
- Norvasc 5 mg daily
- Vit B12 IM q 15 days
- ISS
- KCL 20 [**Hospital1 **]
- NPH 24 Units qam, 12 qpm
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP <100.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Sodium Hypochlorite 0.5 % Liquid Sig: One (1) Appl Miscell.
ASDIR (AS DIRECTED).
7. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Fifteen (15) ML PO TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days.
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. 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
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous Qam.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) units Subcutaneous Qpm.
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day as needed: per Insulin
Sliding Scale.
16. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Im
injection Injection Q 15 DAYS ().
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous see instructions: Please dose by level to complete
a six week course.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
1. Fluid Overload
2. Left necrotic foot ulcer
3. UTI
4. Hypernatremia
....
Secondary Diagnosis:
CAD
DM 2
CRF
Peripheral vascular disease with ulcerations
Anemia
Hypertension
Hypothyroidism
Discharge Condition:
Stable, satting better than 95% on room air. Afebrile. Responds
to her son.
Discharge Instructions:
Please return to the hospital if you wish to undergo amputation
or initiate dialysis. Also return if you experience worsening
shortness of breath, redness of left foot, fever >101.5, or any
other worrisome symptoms.
.
Please take all medications as directed. You have been started
on two antibiotics for infections in your foot and urine.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 30176**] within 1-2 weeks at
[**Telephone/Fax (1) 30177**].
.
If you would like to pursue amputation, please follow-up with Dr
[**Last Name (STitle) **] at [**Telephone/Fax (1) **].
ICD9 Codes: 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4716
} | Medical Text: Admission Date: [**2106-5-17**] Discharge Date: [**2106-5-25**]
Date of Birth: [**2034-9-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Dizziness, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 71 yo male with a past medical history
significant for prior stroke, HTN, and [**First Name3 (LF) 2320**] who obtains routine
medical care from the [**Hospital1 756**] who presented to the ED on [**2106-5-17**]
with the chief complaint of dizziness, progressive lethargy and
confusion x 5 days. The patient reported that in the past 5
days, he noticed increased lethargy and generalized weakness as
well as presyncope with lightheadedness and dizziness but denies
any syncope. He denied any fevers/chills/night
sweats/abdominal/chest pain. His wife noticed the patient's
increased confusion and change in his baseline activity over the
week prior to admission (formerly 1 year ago used to take daily
walks and within past 5 days, couldn't leave his bedroom on the
[**Location (un) 1773**] so that his meals had to be brought to him). He
denies any headache, change in vision (wears glasses at
baseline), or focal weakness or change in balance.
.
Interestingly, the patient notes that he has not felt "well"
over the past 6 months to 1 year with slowly increasing
lethargy. As mentioned, he has slowly cut down on his physical
activity as a result of his fatigue.
.
The patient had seen his PCP 2 weeks ago as part of a routine
physical exam at which time his nifedipine was stopped secondary
to noted hypotension. His wife reports that his physician called
him [**Name Initial (PRE) **] few days later to have his BP rechecked in his office but
the patient did not make it to his appointment. As his symptoms
of lethargy and confusion persisted, his wife called 911. As
[**Hospital1 756**] was on divert, the patient was brought to the [**Hospital1 18**] ED.
.
In the ED, the patient was found to have pancytopenia with a Hct
of 14.5, he was guaiac negative with a SBP initially 86 that
then dropped to 60 with a HR in the 60s. The patient had taken
all of his BP meds on day of admission([**2106-5-17**]) including
atenolol, lisinopril, and HCTZ. His BP rose to 110 with 3 liters
IVF, 3 units PRBC in the ED.
.
His labs were significant for a Hct of 14.5 as mentioned above,
plt 89, WBC 2.9, Cr 1.7, AST 50, LDH 2374, INR 1.4, D-dimer
2608, troponin of 0.02.
.
. 2 large bore IVs were placed in the ED.
.
His EKG was as follows:
.
Initial: NSR 79, Nl axis, RBBB with [**Street Address(2) 1766**] depressions and TWI
V1-v6, <[**Street Address(2) 4793**] depression II ( no prior EKG for comparison)
.
With BP normalization: NSR at 73 bpm, RBBB, NL axis. [**Street Address(2) 4793**]
depressions with biphasic TW V1-V3, normalization of TW V4-V6.
Low voltage.
.
A CT of the head was also performed which showed:
.
1. No acute intracranial hemorrhage. Somewhat limited study due
to motion artifact. Brain atrophy.
.
2. 1.5-cm hypodense area in the right occipital lobe, which may
represent subacute-to-chronic infarction. Clinical correlation
is recommended. MRI will be helpful for further evaluation.
.
The patient has a reported history of stroke in [**2093**] with no
persistent neurologic deficits. He was evaluated by neurology in
the ED who felt his neurologic exam was stable and not
indicative for acute stroke. Based on the CT findings above
which showed subacute/chronic stroke, it was recommended that
prior head imaging be obtained from [**Hospital1 756**] to document his
prior CVA. MRI may be considered otherwise.
.
According to his PCP and [**Name9 (PRE) **] reports, the patient's last Hct was
40 3 years ago with no more recent labs. He had a normal PSA 1
week ago. The patient believes he had a colonoscopy 10-15 years
ago but records from the [**Hospital1 756**] need to be obtained to confirm.
Past Medical History:
HTN
stroke
[**Hospital1 2320**] x 8 years ?
CRI Baseline Cr 1.7 by report (patient was unaware of this)
Social History:
The patient formerly worked in a metal factory 35 years ago and
then as a janitor. He is now retired and lives with his wife in
[**Name (NI) 86**]. They live in a 2-storied single-family home. He denies
any EtOH and formerly only drank on occasion. He is a former
smoker 3 ppd x 12 years - quit 35 years ago.
Family History:
Father, 4 brothers and 1 sister died of MI in 60-70s
Mother deceased from MI as well.
[**Name (NI) 2320**], and HTN run in family. No history of malignancy.
Physical Exam:
Tc in ED 99 P=66 BP86/48->60 systolic ->110 RR 14 99% on RA
.
In MICU
.
Tc=98.6 P= 76 BP = 115/74 RR=16 99% on RA
.
.
Gen - NAD, AOX3, pale, light-skinned African-American male
HEENT - Muddy sclera, anicteric, pale conjunctiva, PERLA, EOMI,
no oral petechiae/mucosal bleeding, no JVD
Heart - RRR, no M/R/G
Lungs - CTAB
Abdomen - Soft, obese, NT, ND, no appreciable
hepatosplenomegaly, active BS
Ext - Onychomycosis bilaterally, no edema, old scars bilateral
LE from burn sustained secondary to work injury 35 years ago, +1
d. pedis bilaterally
Back - No CVAT
Skin - No petechiae, bruising/purpura
Neuro - CN II-XII intact, +2 DTRs x 4, negative Babinski
bilaterally, 5/5 strength x 4
Pertinent Results:
[**2106-5-17**] 09:15PM URINE HOURS-RANDOM
[**2106-5-17**] 09:15PM URINE UHOLD-HOLD
[**2106-5-17**] 09:15PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2106-5-17**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.0
LEUK-NEG
[**2106-5-17**] 09:04PM HGB-5.7* calcHCT-17
[**2106-5-17**] 08:52PM GLUCOSE-200* UREA N-47* CREAT-1.7* SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2106-5-17**] 08:52PM ALT(SGPT)-16 AST(SGOT)-50* LD(LDH)-2374*
CK(CPK)-43 ALK PHOS-94 AMYLASE-34 TOT BILI-1.4
[**2106-5-17**] 08:52PM LIPASE-33
[**2106-5-17**] 08:52PM cTropnT-0.02*
[**2106-5-17**] 08:52PM CK-MB-NotDone
[**2106-5-17**] 08:52PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.6
[**2106-5-17**] 08:52PM HAPTOGLOB-<20*
[**2106-5-17**] 08:52PM WBC-2.9* RBC-1.23* HGB-5.5* HCT-14.5*
MCV-118* MCH-44.4* MCHC-37.5* RDW-17.2*
[**2106-5-17**] 08:52PM NEUTS-67.2 LYMPHS-30.8 MONOS-1.1* EOS-0.9
BASOS-0.1
[**2106-5-17**] 08:52PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+
[**2106-5-17**] 08:52PM PLT SMR-LOW PLT COUNT-89*
[**2106-5-17**] 08:52PM PT-15.6* PTT-26.2 INR(PT)-1.4*
[**2106-5-17**] 08:52PM FIBRINOGE-225 D-DIMER-2608*
.
CT head on [**5-17**]:
1. No acute intracranial hemorrhage. Somewhat limited study due
to motion artifact. Brain atrophy.
2. 1.5-cm hypodense area in the right occipital lobe, which may
represent subacute-to-chronic infarction. Clinical correlation
is recommended. MRI will be helpful for further evaluation.
.
CXR on [**5-17**]:
Apparent mediastinal widening and prominent aortic contours may
be due to AP technique. No prior study available for comparison.
Clinical correlation is advised. If there is concern for aortic
pathology, chest CT could be performed.
.
EKG on [**5-17**]:
Sinus rhythm, Right bundle branch block, Left atrial
abnormality, Diffuse ST-T wave abnormalities -are in part
primary and suggest ischemia - clinical correlation is
suggested. No previous tracing available for comparison.
.
EKG on [**5-18**]:
Sinus rhythm, Right bundle branch block, Left atrial
abnormality, Anterolateral ST-T wave abnormalities -may be in
part primary and are
nonspecific - clinical correlation is suggested. Since previous
tracing of same date, no significant change.
.
EKG on [**5-19**]:
Mild congestive heart failure with cardiomegaly and small
bilateral pleural effusion.
.
EEG on [**5-19**]:
Abnormal EEG in the waking and drowsy states due to the
moderate slowing of the background in wakefulness. This suggests
a
widespread encephalopathy. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no areas
of
persistent focal slowing, and there were no epileptiform
features.
.
Labs on d/c:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-5-25**] 05:45AM 6.1# 2.90* 9.8* 27.8* 96 33.8* 35.2*
20.7* 126*#
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2106-5-17**] 08:52PM 67.2 30.8 1.1* 0.9 0.1
RED CELL MORPHOLOGY Anisocy Poiklo Macrocy
[**2106-5-17**] 08:52PM 1+ 1+ 3+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2106-5-25**] 05:45AM 126*#
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
FDP D-Dimer
[**2106-5-18**] 10:15AM 10-40
[**2106-5-18**] 03:27AM [**Telephone/Fax (1) 39386**]*
HEMOLYTIC WORKUP Ret Aut
[**2106-5-22**] 06:35AM 3.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-5-23**] 05:45AM 159* 19 1.0 139 4.2 107 24 12
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2106-5-22**] 06:35AM 1188*
OTHER ENZYMES & BILIRUBINS Lipase GGT
[**2106-5-18**] 03:27AM 20
CPK ISOENZYMES CK-MB cTropnT
[**2106-5-20**] 05:50AM NotDone1 0.04*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2106-5-22**] 06:35AM 8.4 3.2 2.0
HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF
[**2106-5-22**] 06:35AM GREATER TH1
1 GREATER THAN [**2099**]
PITUITARY TSH
[**2106-5-18**] 03:27AM 1.3
THYROID Free T4
[**2106-5-18**] 03:27AM 1.0
HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HBc IgM HAV
[**2106-5-18**] 03:27AM NEGATIVE NEGATIVE NEGATIVE POSITIVE
NEGATIVE NEGATIVE
HIV SEROLOGY HIV Ab
[**2106-5-18**] 03:27AM NEGATIVE
CONSENT RECIEVED
LAB USE ONLY RedHold
[**2106-5-18**] 12:15AM HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS Intubat
[**2106-5-18**] 10:31AM [**Last Name (un) **] 37.2 24*1 39 7.38 24 -2 NOT
INTUBA2
1 NO CALLS MADE - NOT ARTERIAL BLOOD
2 NOT INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2106-5-18**] 10:31AM 1.7
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2106-5-17**] 09:04PM 5.7* 17
CALCIUM freeCa
[**2106-5-18**] 10:31AM 1.19
.
Negative Parvo IgM.
Brief Hospital Course:
# Pancytopenia:
On admission the patient was found to be pancytopenic - Hct
14.5, WBC 2.9, ptl 89. The initial differential included
idiopathic, medication-induced aplastic anemia (nifedipine,
NSAIDs), viral-induced aplastic anemia (HIV, parvo B19),
myelodysplastic syndrome (?lymphoma or other malignancy), TTP
(without fever, acute renal dysfunction, with mental status
changes, anemia, and thromboctopenia)or DIC with elevated INR.
There was evidence of hemolysis with LDH in [**2099**] range and hapto
<20, D-dimer 2600. The patient received 3 units PRBC in the ED
and was transfered to the MICU for further monitorin of his
hypotension. He was given an additional 2 Units of PRBC in the
MICU. His Hct rose appropriately to PRBC, being 30.3 after a
total of 5 Units given. The peripheral smear was most notable
for polychromatophilia and anisocytosis. The obtained additional
labs revealed a Vit B12 deficiency (75), Folate normal (6.2),
elevated Iron (233) and Ferritin (624) and low TiBC (186).
Parameters indicating Hemolysis were low: Hapto(<20), elevated
tBili (2.6) and dBili 0.7. The Retic Count of 0.9 showed
impaired production in the BM.
Given that the pt was Vit B12 deficient and that is presentation
could be well explained a possible BM biopsy was postponed. He
was started on Cyanocobalamin 1000mcg sc/im daily and Folate 5mg
iv daily. The LDH increase persisted initially, and then started
to steadily go down, same with tBili. Since his Retic Count did
not respond as expected to Vit B12 supplementation (being 0.4 on
[**5-20**]) a bone marrow biopsy was obtained (on [**5-20**]) to r/o an
additional hemolytic disorder, such as AML, aplastic anemia. The
BM biopsy confirmed the diagnosis of Vit B12 deficiency as the
underlying disorder and showed no signs of leukemia.
The pt was kept inpatient over the weekend because his
thrombocytes continously dropped (32 on [**5-21**]) despite the
initiated Vit B12 therapy; however, his platelets gradually
increased and he was discharged to rehab with all counts
trending upwards.
.
# Hypotension
On admission the pt presented with BP of 86/48. He reported
light-headnesses and dizziness but denied syncopal episodes,
falls, CP or SOB. His physical exam did not reveal signs of HF,
such as increased JVD, hepatojugular reflux, ascites or
peripheral edema. His hypotension was [**Month/Year (2) 2771**] to dehydration
and his BP was successfully elevated by volume resuscitation (3l
of IVF and 5 Units of PRBC) and d/c of home BP-meds. He was
transfered to the MICU for overnight supervision. His SBPs have
remained stable over the rest of his hospital stay (SBP 110-130)
and he was put back on Lisinopril 10mg po daily. Before
discharge patient's blood pressure improved and he was restarted
on atenolol 25 with SBP 100-110 range.
.
# Lethargy, confusion
Pt presented with 5 days h/o worsening confusion, possible
baseline dementia, to the ED. He has a PMH for stroke in [**2093**],
with no residual deficits per wife. In the ED a CT of the head
was obtained to r/o possible stroke as cause for MS changes. It
showed subacute/chronic infarcy in right occipital lobe. Neuro
evaluated the patient in the ED and felt that this was most
likely consistent with chronic infarct. Pt had waxing and [**Doctor Last Name 688**]
episodes of confusion (disoriented to date, location and
context; agitation) when still on the MICU and after he was
transfered to the floor. Since the CT had been negative for
acute bleeding, the changes in his MS [**First Name (Titles) **] [**Last Name (Titles) 2771**] to his
hypotension on presentation as well as to the Vit B12
deficiency. A EEG was performed, following neuro recs, which
showed widespread encephalopathy. Since the pt MS improved over
the course of his hospital stay, and considering the facts
presented above, Neuro did not think that a MRI of his head was
indicated for further work-up.
Patient is likely to have baseline dementia (atrophy seen on
initial CT) and (resolving) neurologic manifestation from Vit
B12 deficiency.
.
# EKG changes
The EKG drawn in the ED showed the following abnormalities:
RBBB, ST-depressions and TWI in V1-V6, which were thought to be
a result of demand ischemia. His CK was 43 and his Troponin
0.02. There was only little suspicion for ACS as the etiology
for his hypotension, since the pt had no complaints of shortness
of breath/chest pain or radiating pain.
EKG and Troponin were monitored closely over the following days
and resolved after the pt was normotensive and had received
PRBC. A repeat EKG on [**5-19**] showed RBBB, no remaining
ST-depressions or TWI. His Troponin on [**5-20**] was 0.04. He was
started on Lipitor 10mg daily.
Given the pt PMH and his strong FH for CAD, he should receive
outpatient work-up of underlying CAD.
.
# Chronic renal insufficiency
Creatinine presented with Creatinine of 1.7 on admission, which
was his baseline Crea according to old recs. The chronic renal
insufficiency might be due to diabetic nephropathy. However,
since the creatinine steadily improved over the course of the
hospital stay, being 1.1 on [**5-21**], a prerenal component
(secondary to dehydration) was thought to play a key role.
.
# [**Name (NI) 2320**]
Pt has a h/o DM, which he is seen for by his PCP at the [**Name9 (PRE) 112**]. On
admission he was on oral hypoglycemics, metformin and glyburide,
but was changed to a ISS (Humalog). Patient was subsequently
restarted on his oral hypoglycemic before discharge with
suplemental sliding scale.
Medications on Admission:
Atenolol 75 mg PO QD
Lisinopril 40 mg PO QD
Glyburide 5 mg QD
Metformin 500 mg [**Hospital1 **]
HCTZ 25 mg PO QD
ASA 81
stopped Nifedipine 30 mg QD 2 weeks ago
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Vitamin B12 deficiency
pernicious anemia
pancytopenia
mental status changes
Peripheral Neuropathy
HTN
DM
CRI
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as listed below.
Please see your primary care physician or come to the ED if you
notice any of the following symptoms: Headache, dizziness,
changes in vision, nausea, vomiting, shortness of breath, chest
pain, confusion, increased weakness in legs or tendency to fall
or any other reasons that are concerning you.
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39387**] in [**12-28**] weeks after
discharge.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 39387**] on Tuesday [**5-25**]. Call
1-800-[**Hospital1 112**]-999 for an appointment.
Test for consideration post-discharge: CBC, Reticulocyte count,
Intrinsic Factor Antibody, Anti Parietal Cell Antibody with
referral to GI based on results.
Consider outpatient stress test for EKG changes and slightly
elevated troponin on presentation.
.
Please follow up with Dr. [**Last Name (LF) 5561**], [**First Name3 (LF) **] in Hematology.
We scheduled an appointment with her for you on [**2106-5-25**] at
11.30am, at the [**Hospital1 18**]. Phone:[**Telephone/Fax (1) 22**]
ICD9 Codes: 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4717
} | Medical Text: Admission Date: [**2167-7-13**] Discharge Date: [**2167-7-18**]
Date of Birth: [**2167-7-13**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 61975**] is the 1835 gram product of a 32
week gestation, born to a 28 year old gravida I, para 0, now
I, female. Prenatal screens O positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis surface antigen
negative, and GBS negative. Maternal history of asthma and an
eating disorder. Pregnancy complicated by premature
contractions on [**7-6**], treated with magnesium sulfate and
betamethasone. Transferred from [**Hospital3 1196**] on
[**7-9**], secondary to cervical change despite magnesium
sulfate. Spontaneous rupture of membranes 2 hours prior to
delivery. No intrapartum antibiotics. Vaginal delivery under
epidural anesthesia. Apgar was assigned as 8 and 9.
PHYSICAL EXAMINATION: On admission, birth weight 1835 grams,
75th percentile, length 43 cm, 50th percentile, head
circumference 28 cm, 10th to 25th percentile. Anterior
fontanelle soft, flat, significant molding, nondysmorphic,
normal red reflex bilaterally, intact palate. Clear breath
sounds. Grade II/VI murmur. Normal pulses. Soft abdomen, 3
vessel cord, no hepatosplenomegaly. Normal female genitalia.
Patent anus. No hip clicks, no sacral dimple. Normal tone and
activity. Moves all extremities well.
HOSPITAL COURSE: Respiratory: The infant was admitted to the
newborn intensive care unit and remained in room air for the
first 24 hours of age. Increased onset of apnea and
bradycardia episodes prompted nasal cannula flow. The infant
continued to have increase in apnea and bradycardia at which
time sepsis evaluation was performed. The infant was started
on CPAP of 5 cm of water in room air and was loaded with
caffeine citrate. She remained on CPAP for less than 24 hours, at
which time she was weaned to room air with improvement in her
apnea. She continues on caffeine citrate at 7
mg/kg/day and has mild to moderate apnea and bradycardia
episodes.
Cardiovascular: There were no issues.
Fluids, electrolytes and nutrition: Birth weight was 1835
grams. Initially started on 80 cc/kg/day of D10W. Enteral
feedings were initiated on day of life #1. The patient
reached full enteral feedings by day of life #4 and is
currently received p.o. PG feeds of 140 cc/kg/day of
premature Enfamil or breast milk.
GI: The infant did receive phototherapy for a peak bilirubin of
11.8 on day of life #2. Phototherapy was discontinued on DOL
#5, [**7-18**], for a bilirubin of 7.1, with a rebound on the day of
transfer of 9.7.
Hematology: Hematocrit on admission is 39.1. The infant's
blood type is A positive, Coombs negative. She has not
received any blood transfusions during this hospital course.
Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained negative at
48 hours at which time antibiotics were discontinued.
Neurology: The infant has been appropriate for gestational
age. Head ultrasound was performed on day of life #2 secondary to
the increased apnea spells, and was within
normal limits.
Sensory: Hearing screen has not been performed but should be
done prior to discharge to home.
Psychosocial: Parents have been involved and intact.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To [**Hospital3 1196**].
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 63786**], telephone number [**Telephone/Fax (1) 63787**].
CARE RECOMMENDATIONS:
1. Continue feeding of 140 cc/kg/day of breast milk or
premature Enfamil 20 calorie. Advance calorie intake as
appropriate for maintaining weight gain.
2. Medications: Caffeine citrate at 7 mg/kg/day.
3. Car seat position screening has not been done prior to
discharge, to be done prior to discharge to home.
4. State newborn screen most recently sent on [**2167-7-16**].
5. Immunizations received: The infant has received no
immunizations thus far.
DISCHARGE DIAGNOSES: 32 week female.
Rule out sepsis.
Apnea and bradycardia of prematurity.
Hyperbilirubinemia.
DR [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2167-7-18**] 05:31:39
T: [**2167-7-18**] 08:19:27
Job#: [**Job Number 63788**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4718
} | Medical Text: Admission Date: [**2113-6-16**] Discharge Date: [**2113-7-5**]
Date of Birth: [**2038-5-30**] Sex: F
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
woman with a history of hypertension, hypercholesterolemia,
and asthma, who developed a vague cough and some right-sided
chest discomfort about a year ago. A chest CT showed a 4.6 x
4.4 cm mass in the posterior segment of the right upper lobe.
It was noted to abut the esophagus and invade the right
paraspinal area. There were 1 cm pretracheal nodes. On
[**2112-12-16**], the patient underwent bronchoscopy that
demonstrated chronic inflammation with focal epithelial
atypia. On [**2113-2-8**], the patient underwent a PET scan that
showed increased activity in the right upper lobe mass, the
right hilar lymph node, and some moderately increased uptake
in the pretracheal lymph nodes. On [**2113-2-16**], the patient
underwent a diagnostic mediastinoscopy. All 35 nodes were
negative. On [**2113-3-10**], the patient underwent a thorascopic
evaluation with biopsy of the right hilar lymph node.
Pathology demonstrated non-small cell lung cancer with
squamous differentiation. At the time of surgery, the right
upper lobe was found to invade along the broad surface into
the vertebral column. It was decided that the patient would
be best served by receiving preoperative chemo-radiation. At
this point, she had experienced a 7 pound weight loss over 3
months and her appetite has been a little lower than usual.
She denied shortness of breath but did have some dyspnea on
exertion after walking up one flight of stairs.
A restaging set of PET and CT scans showed significant
decrease in activity within the right upper lobe mass and
hilar lymph nodes as well as significant reduction in the
overall size on CT scan. There was, however, an area of bony
erosion where the tumor abuts the vertebral column. MRI
showed a more extensive involvement of the vertebral body.
It was decided to have Dr. [**Last Name (STitle) 739**] of neurosurgery to
participate in the resection.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Asthma.
Sinus surgery in the past.
Hand surgery.
CURRENT MEDICATIONS: Percocet p.r.n.
Hydrochlorothiazide 25 mg q.day.
Tenormin 100 mg p.o. q.day.
Diovan 80 mg p.o. b.i.d.
Lipitor 10 mg p.o. q.day.
PHYSICAL EXAMINATION: General: The patient is a well-
developed elderly female who is active.
Vital Signs: Blood pressure 120/74, pulse 66, temperature
97.1, weight 149, oxygen saturation 97 percent on room air.
HEENT; Sclerae anicteric. Pupils equal, round and reactive.
Chest: Lungs are clear to auscultation and bilaterally
equal. Thorax is symmetrical without masses.
Heart: Regular without murmur.
Abdomen: Benign.
Extremities: No clubbing or edema.
Neurologic: Grossly nonfocal with an intact and appropriate
mental status.
Skin: No lesions.
HOSPITAL COURSE: On [**2113-6-16**], the patient underwent a right
thoracotomy with right upper lobectomy, radical mediastinal
lymph node dissection and an intercostal muscle flap to the
bronchial stump. Dr. [**Last Name (STitle) 739**] of neurosurgery performed
a partial body resection of T4 and T5. At the time of
surgery, the margins were clear. The patient tolerated the
procedure well. Please see dictated Operative Notes for
further details. The patient was kept intubated overnight
and was extubated the following morning without incident.
Over the following three days, the patient experienced some
post-op oliguria which resolved with several fluid boluses.
Lasix was then begun for diuresis. On post-op day two, the
patient was noted to need aggressive chest PT which she did
receive. On post-op day three, the patient's hematocrit had
dropped to 27.2 and she received a unit of packed red blood
cells. This brought her hematocrit up to 32.5.
The patient also underwent a speech and swallowing evaluation
which she failed. Therefore, a feeding tube was placed and
her tube feeds were slowly advanced to goal.
Post-op day four was the first day the patient experienced a
negative fluid balance. This continued through most of her
hospital stay. On post-op day five, the patient continued to
do well and was transferred to the floor. On post-op day
six, the patient was found to be in sinus tachycardia with
wheezing and a chest x-ray showed collapse of the right upper
and right lower lobes. The patient was, therefore,
transferred to the ICU. Over the course of the following
day, the patient underwent two bronchoscopies with suction of
copious amounts of fluid. On post-op day seven, the patient
was noted to have methemoglobinemia, presumably secondary to
benzocaine use. The patient was treated with methylene blue
and improved.
On post-op day eight, a sputum showed gram-negative rods and
the patient was started on levofloxacin. This antibiotic was
continued until post-op day 14. Also on that day, a post-
pyloric feeding tube was placed. The chest x-ray was noted
to be worse on this day and chest PT continued. On post-op
day 11, the patient experienced right arm swelling. The
patient underwent a right upper extremity ultrasound which
showed a right cephalic and right internal jugular deep vein
thrombosis. The patient was begun on a heparin drip and
eventually transitioned to Coumadin with a goal INR of 2 - 3.
The most appropriate Coumadin dose seemed to be 2.5 mg q.day.
Also on post-op day 11, the chest x-ray was noted to be
slightly improved. On post-op 12, a PICC was obtained for
I.V. access.
The patient also underwent a re-evaluation of her swallowing
function and was found to tolerate thin liquids. The post-
pyloric feeding tube was, therefore, removed. On post-op day
14, the patient continued to do well but a chest x-ray showed
a possible right lung collapse. A bronchoscopy revealed a
large amount of mucopurulent secretions in the right middle
and lower lobes. The patient was continued on PT and
diuresis. On post-op day 17, the patient was transfused for
a hematocrit of 24.6, which brought her up to a hematocrit of
33.9. By post-op day 19, the patient was therapeutic on
Coumadin and chest x-ray showed improved aeration of the
right middle and lower lobes. She had experienced no
desaturation episodes over the preceding several days. She
looked well and was discharged to rehab on Coumadin with
aggressive chest PT.
DISPOSITION: To rehab facility.
DISCHARGE DIAGNOSES: In addition to the admitting diagnoses
listed above in the past medical history, the patient has
adenocarcinoma of her right upper lobe, status post right
upper lobectomy, and metastatic carcinoma to her vertebral
soft tissue.
DISCHARGE MEDICATIONS: Warfarin 2.5 mg p.o. q.day.
Ipratropium nebs.
Albuterol nebs.
Metoprolol 37.5 mg p.o. t.i.d.
Lasix 20 mg p.o. b.i.d.
Protonix 40 mg p.o. q.day.
Dextromethorphan/Guaifenesin.
Ibuprofen 400 mg p.o. q.6 hours
Percocet 5/325 p.o. q.4-6 hours p.r.n.
FOLLOW UP PLAN: The patient is to call Dr.[**Name (NI) 1816**] office
to schedule a followup appointment in one to two weeks.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2113-7-5**] 21:09:44
T: [**2113-7-5**] 23:18:34
Job#: [**Job Number 49665**]
ICD9 Codes: 5180, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4719
} | Medical Text: Admission Date: [**2170-1-15**] Discharge Date: [**2170-1-23**]
Date of Birth: [**2149-4-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
acetaminophen overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 year old generally healthy gentleman was found to be confused
and naked this morning. Patient states that he was depressed and
took 2 bottles of tylenol PM (150 tablets 500/125mg). He was
found by his friend. [**Name (NI) **] was taken to [**Hospital6 3105**].
His APAP level at 10:45 am was 323 with lactate of 8.1. He
received NAC loading dose of 150 mg/kg over one hour and then
drip per NAC protocol. He also received 2L of NS per verbal
report and was transferred to [**Hospital1 18**].
In [**Hospital1 18**] ED his vitals were T 98.4 BP 140/90 HR 100 RR 20 99%
RA. Patient received 2L of NS, zofran 4 mg IV once, tetanus shot
and NAC at 17 mg/kg/hr infusion. He experienced nonbloody
nonbilious vomitting in the ED.
On arrival to MICU his vitals were HR 107 BP 167/77 RR 18 98% in
RA. Patient denied any chest pain, shortness of breath or
abdominal pain. He felt depressed yesterday. He felt that he was
alone and has some trouble at work. He denied any prior
suicidal/homicidal attempts.
Past Medical History:
- MVC 3 days prior to admission
- Seizure when he was 7 years old, on dilantin for approx 2
years
Social History:
Lives by himself. Works at a grocery store. Mother and sister
lives nearby. Non smoker. Denies any street drug use. Occasional
ETOH. Last drink one week ago.
Family History:
Sister has depression
Physical Exam:
Vitals: HR 107 BP 167/77 RR 18 98% in RA
Gen: Awake and oriented x 3 (knows he is in ICU but called the
hospital as [**Hospital3 **])
HEENT: PERRL, EOM-I, OP clear, JVP not elevated
Heart: S1S2 Regular rhythm, tachycardic, no MRG
Lungs: CTAB
Abdomen: BS present, soft NTND, no appreciable mass/organomegaly
Ext: WWP, no edema
Neuro: CN II-XII grossly intact, strength 5/5 bilat, sensation
intact
Psych: Depressed mood
Pertinent Results:
[**2170-1-15**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-1-15**] 02:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2170-1-15**] 02:35PM PT-18.4* PTT-40.1* INR(PT)-1.7*
[**2170-1-15**] 02:35PM PLT COUNT-303
[**2170-1-15**] 02:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2170-1-15**] 02:35PM NEUTS-78* BANDS-2 LYMPHS-3* MONOS-14* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2170-1-15**] 02:35PM WBC-10.2 RBC-4.96 HGB-15.5 HCT-41.5 MCV-84
MCH-31.3 MCHC-37.3* RDW-12.6
[**2170-1-15**] 02:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-1-15**] 02:35PM URINE GR HOLD-HOLD
[**2170-1-15**] 02:35PM URINE HOURS-RANDOM
[**2170-1-15**] 02:35PM URINE HOURS-RANDOM
[**2170-1-15**] 02:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-272*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-1-15**] 02:35PM CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.6
[**2170-1-15**] 02:35PM LIPASE-65*
[**2170-1-15**] 02:35PM ALT(SGPT)-145* AST(SGOT)-96* CK(CPK)-248* ALK
PHOS-64 TOT BILI-1.1
[**2170-1-15**] 02:35PM estGFR-Using this
[**2170-1-15**] 02:35PM GLUCOSE-194* UREA N-10 CREAT-0.9 SODIUM-136
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-18* ANION GAP-19
[**2170-1-15**] 02:46PM LACTATE-2.7*
[**2170-1-15**] 02:46PM PO2-72* PCO2-32* PH-7.32* TOTAL CO2-17* BASE
XS--8 COMMENTS-GREEN TOP
[**2170-1-15**] 06:45PM ACETMNPHN-175.3*
[**2170-1-15**] 10:57PM LACTATE-1.1
[**2170-1-15**] 10:57PM TYPE-[**Last Name (un) **] PO2-88 PCO2-33* PH-7.35 TOTAL
CO2-19* BASE XS--6
[**2170-1-15**] 10:58PM PT-22.8* PTT-48.2* INR(PT)-2.2*
[**2170-1-15**] 10:58PM PLT COUNT-293
[**2170-1-15**] 10:58PM WBC-18.8*# RBC-4.80 HGB-14.9 HCT-40.1 MCV-84
MCH-31.2 MCHC-37.3* RDW-12.9
[**2170-1-15**] 10:58PM CALCIUM-8.6 PHOSPHATE-2.4* MAGNESIUM-1.8
[**2170-1-15**] 10:58PM ALT(SGPT)-147* AST(SGOT)-96* LD(LDH)-278* ALK
PHOS-59 TOT BILI-2.2*
[**2170-1-15**] 10:58PM GLUCOSE-75 UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-16* ANION GAP-18
[**2170-1-20**] 04:45AM BLOOD WBC-5.4 RBC-4.08* Hgb-12.9* Hct-34.1*
MCV-84 MCH-31.6 MCHC-37.7* RDW-12.1 Plt Ct-198
[**2170-1-19**] 05:45AM BLOOD WBC-6.7 RBC-4.28* Hgb-13.5* Hct-36.0*
MCV-84 MCH-31.6 MCHC-37.6* RDW-12.1 Plt Ct-176
[**2170-1-20**] 04:45AM BLOOD PT-13.7* PTT-37.2* INR(PT)-1.2*
[**2170-1-19**] 05:45AM BLOOD PT-14.4* INR(PT)-1.2*
[**2170-1-20**] 04:45AM BLOOD Glucose-77 UreaN-29* Creat-3.3* Na-142
K-3.5 Cl-109* HCO3-23 AnGap-14
[**2170-1-19**] 05:45AM BLOOD Glucose-75 UreaN-29* Creat-3.3* Na-141
K-3.3 Cl-108 HCO3-22 AnGap-14
[**2170-1-20**] 04:45AM BLOOD ALT-[**2065**]* AST-54* AlkPhos-64 TotBili-0.8
[**2170-1-19**] 05:45AM BLOOD ALT-3060* AST-171* AlkPhos-65 TotBili-1.1
[**2170-1-20**] 04:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.2
[**2170-1-19**] 05:45AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3
.
REPORTS:
[**1-15**] CT Head: No acute intracranial pathology.
[**1-15**] CT C-spine: No evidence of acute fracture or malalignment.
.
[**1-16**] TTE: The left atrium is normal in size. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. 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 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 pericardial effusion.
.
[**1-16**] RUQ U/S: Unremarkable ultrasound. Patent vasculature.
.
[**1-18**] Renal U/S: Increased renal parenchymal echogenicity,
likely due to medical renal disease. No hydronephrosis.
.
[**1-22**] Left Upper Extremity U/S: Findings consistent with clot
formation of the antecubital vein without extension into the
brachial, basilic or central veins as described above.
Brief Hospital Course:
20M s/p tylenol overdose suicide attempt w hepatotocity and
acute renal failure. The pt ingested a total of 75g of tylenol
and 18.5g of benadryl. He presented to the OSH 12hr after the
ingestion and was started on a NAC protocol. At the time, his
tylenol level was 272. He was taken to the MICU, where
supportive measures were implemented and he was assessed for
transplantation. However, he did not meet criteria. His LFTs
maxed on [**1-16**] with ALT [**Numeric Identifier 81416**], AST [**Numeric Identifier 16106**], INR 4.1. In the MICU,
he did not require ventilatory support. He did develop acute
renal failure, with a creatinine that rose from 0.9 [**1-15**] to 3.3
[**1-19**]. A renal consult was called; their assessment was that the
pt had intrinsic acute renal failure due to direct acetaminophen
toxicity. His creatinine was trended and his diet was advanced
slowly. NAC was d/c'd on [**1-18**], as INR had normalized, the pt's
LFTs were trending down and his APAP level was negative. From a
psychiatric perspective, the pt stated that the overdose was
pre-planned as a suicide attempt. He did not endorse suicidality
to the primary team during his stay. Psychiatry was consulted
and recommeded a sitter at all times and inpatient psychiatric
treatment when medically cleared. On [**1-21**], the patient was felt
to be medically stable from both a renal and hepatic perspective
for transfer to a psychiatric facility. On the same date, the
patient was noted to have a red, swollen region on his left
forearm. U/S showed superficial clot in the antecubital vein.
Because of the redness and a leukocytosis, the patient was given
IV antibiotics for 1 day and then converted to PO keflex for a 7
day total course. On [**1-23**], the redness and swelling was much
improved and the leukocytosis had resolved.
.
# Tylenol OD/ Acute Hepatic Injury: Time of ingestion around
10:30pm on [**2170-1-14**]. Tylenol level at 2:35 pm on [**2170-1-15**] was
272, 6 pm 175, 75 at 4AM. Tylenol level negative [**2170-1-18**].
Urine and serum tox screen was otherwise negative. Toxicology,
Hepatology, Neurosurgery, and Transplant have been following. At
time of discharge, coagulopathy had resolved and LFTs were
trending toward normal. The patient should be seen in follow up
at liver clinic as scheduled.
.
# Acute Renal Failure: Likely from Tylenol OD (renal impairment
usually occurs at 48-72 hours) from direct toxicity/ATN picture
w a prerenal component. Cr plateauing as of [**1-20**] at 3.3. The
patient did not require dialysis. He had excellent urine output
and was felt to have reversible ATN. At time of discharge, plan
to check creatinine at psych facility 1-2 times weekly to ensure
decline with follow up at renal clinic in 1 month.
.
# Suicidal attempt. Psych following while in house. At time of
discharge, patient was to be transferred to inpatient psych for
further evaluation.
.
On [**1-23**], the patient was felt to be medically stable by all
medical teams with improving labs and stable vital signs. He was
discharged with plan for follow up.
Medications on Admission:
vitamins
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 6 days.
Disp:*18 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**]- [**Hospital1 **] 4
Discharge Diagnosis:
Tylenol hepatotoxicity
Tylenol nephrotoxicity
Suicide attempt
Left Antecubital Vein Thrombophlebitis
Discharge Condition:
Good
Discharge Instructions:
You have been evaluated and treated in the hospital for your
tylenol overdose. You sustained liver and kidney damage from the
tylenol poisoning. Both have improved during your stay in the
hospital. You were initially treated in the intensive care unit
due to the severity of your liver injury.
.
You were also evaluated for your suicide attempt and other
mood-related symptoms. Psychiatry recommended that you recieve
inpatient psychiatric treatment once you are medically cleared.
.
Please call your primary care doctor or return to the emergency
department if you have:
- thoughts of hurting yourself or others
- chest pain or shortness of breath
- profuse bleeding
- inability to keep food down
- fever > 102F
- anything concerning
Followup Instructions:
Please follow-up at the appointments as indicated below. You
must identify a primary care physician before attending these
appointments and obtain a referral in order for you to be
covered under your insurance carrier.
Kidney Clinic [**Location (un) 436**] [**Hospital Ward Name 23**] Building --- [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**],
M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2170-2-22**] 1:00
Liver Clinic --- [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2170-4-16**] 12:10
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4720
} | Medical Text: Admission Date: [**2148-7-1**] Discharge Date: [**2148-7-9**]
Date of Birth: [**2074-1-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
AMS, low urine output
Major Surgical or Invasive Procedure:
[**2148-7-1**]: s/p Right knee replacement
History of Present Illness:
74 yo male with h/o DM2, HTN, CAD with stent placement, one
kidney, Parkinson's dz. End-stage tricompartmental OA, presented
for right TKR.
After surgery, patient was somnolent and with low urine output.
In OR/PACU patient received 4L liters fluids + 500 cc 5%
albumin, with UOP 376cc (10-20 cc/hr). Patient developed
increasing somnolence throughout the day. Received total 1.5mg
dilaudid per PCA in PACU. He also received 1g tylenol and 4U
insulin SC. Creatinine was 1.3 (baseline 1.0-1.2). Hematocrit
25 at 5pm, subsequently 23 (baseline 30-33). ABG 7.42/44/64/30.
Vitals in PACU:
T 96.8-97.4 HR 50-100 BP 120s/50s RR 15-20 O2Sa 98-99% on 2L
Vitals on arrival to the MICU:
T 100.1 HR 102 BP 141/62 RR 22 SaO2 96% on 2L NC
Upon transfer to the MICU he was transfused 1U RBC followed by
20mg Lasix, after which UOP rose to ~100cc/hr.
Past Medical History:
1)3VCAD
- s/p STEMI and PTCA of LAD [**2141**] at [**Hospital1 2177**]
- s/p PTCA & DES to OM1 [**2146-2-18**]
- s/p DES to prox/mid-LAD & OM1 [**2147-2-16**]
- s/p stent & balloon angioplasty to LAD [**2147-12-20**]
- ECG [**2148-6-26**]: notable for SR, PR 214, poor R wave progression,
nonspecific lateral lead ST-T wave abnormalities
2)Hypertension
3)Dyslipidemia
4)BPH
5)Type 2 diabetes with peripheral neuropathy
6)s/p R nephrectomy ~10 years ago at [**Hospital1 2177**] - path benign per
patient
7)Parkinson's disease:
- diagnosed age 70
- followed as outpatient by Dr. [**First Name (STitle) 951**].
- Carbidopa/levodopa
8)Bells' palsy ([**2-1**] HTN) [**6-8**] s/p valtrex
9)CKD Stage II baseline 1.0-1.2
10)Depression
11)Microcytic anemia-stable all his life-?thalassemia. neg,
[**Last Name (un) **]-egd in past
12)Elevated PSA
13)Urinary frequency and incomplete emptying on UDS
14)Knee arthritis
Social History:
Lives with his wife and son. Retired [**Name2 (NI) 13222**] at [**Hospital1 **]. No
smoking, drinking or illicit drug use. Does work part-time now
at a gun and rifle club. Notes that his diet is not good -->
pizza, sandwiches.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Foley catheter, remove [**2148-7-13**] at 6am
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Sanguinous drainage from proximal wound, dressed with silver
nitrate and steristrips placed on [**7-6**], good effect
* Eccymosis medial/lateral knee and shin
* Thigh full but soft
* No calf tenderness
* SILT, NVI distally
* Toes warm
* +cap refill
* WEAK PT, -AT
Pertinent Results:
CXR [**2148-7-1**]: Low lung volumes. Interval appearance of mild
interstitial edema and engorged pulmonary vasculature. Heart
size is increased. Bibasilar opacities likely atelectasis.
Stomach is distended with gas.
[**2148-7-9**] 07:30AM BLOOD WBC-9.9 RBC-3.66* Hgb-9.2* Hct-28.6*
MCV-78* MCH-25.1* MCHC-32.1 RDW-17.6* Plt Ct-331
[**2148-7-8**] 07:05AM BLOOD WBC-8.6 RBC-3.62* Hgb-9.5* Hct-28.2*
MCV-78* MCH-26.3* MCHC-33.7 RDW-16.9* Plt Ct-268
[**2148-7-8**] 01:00AM BLOOD WBC-8.4 RBC-3.53* Hgb-9.3*# Hct-27.0*
MCV-76* MCH-26.2* MCHC-34.3 RDW-16.9* Plt Ct-262
[**2148-7-7**] 05:30AM BLOOD WBC-6.6 RBC-2.99* Hgb-7.3* Hct-22.6*
MCV-76* MCH-24.4* MCHC-32.2 RDW-16.9* Plt Ct-205
[**2148-7-6**] 08:00AM BLOOD WBC-7.8 RBC-3.26* Hgb-7.9* Hct-24.3*
MCV-75* MCH-24.2* MCHC-32.4 RDW-16.8* Plt Ct-187
[**2148-7-5**] 08:00AM BLOOD WBC-8.4 RBC-3.54* Hgb-8.8* Hct-26.4*
MCV-75* MCH-24.8* MCHC-33.2 RDW-16.6* Plt Ct-145*
[**2148-7-4**] 07:55AM BLOOD WBC-10.0 RBC-3.36* Hgb-7.9* Hct-24.5*
MCV-73* MCH-23.4* MCHC-32.2 RDW-16.6* Plt Ct-116*
[**2148-7-3**] 07:35AM BLOOD WBC-11.7* RBC-3.60* Hgb-8.3* Hct-25.5*
MCV-71* MCH-23.2* MCHC-32.7 RDW-15.3 Plt Ct-130*
[**2148-7-2**] 03:22AM BLOOD WBC-9.6 RBC-4.06* Hgb-9.4* Hct-28.8*
MCV-71* MCH-23.1* MCHC-32.6 RDW-15.6* Plt Ct-119*
[**2148-7-1**] 05:30PM BLOOD WBC-9.8 RBC-3.58*# Hgb-7.9*# Hct-25.2*#
MCV-70* MCH-22.0* MCHC-31.4 RDW-15.7* Plt Ct-145*
[**2148-7-1**] 05:30PM BLOOD Neuts-78.4* Lymphs-15.8* Monos-5.0
Eos-0.5 Baso-0.3
[**2148-7-8**] 07:05AM BLOOD PT-11.5 INR(PT)-1.1
[**2148-7-9**] 07:30AM BLOOD Glucose-184* UreaN-23* Creat-0.9 Na-133
K-4.2 Cl-98 HCO3-26 AnGap-13
[**2148-7-8**] 07:05AM BLOOD Glucose-204* UreaN-28* Creat-0.9 Na-134
K-3.9 Cl-97 HCO3-27 AnGap-14
[**2148-7-7**] 05:30AM BLOOD Glucose-168* UreaN-33* Creat-1.1 Na-134
K-3.6 Cl-98 HCO3-26 AnGap-14
[**2148-7-8**] 07:05AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
[**2148-7-7**] 05:30AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.3
[**2148-7-6**] 08:00AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.4
[**2148-7-1**] 07:37PM BLOOD Type-ART O2 Flow-2 pO2-64* pCO2-44
pH-7.42 calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2148-7-1**] 07:37PM BLOOD Hgb-7.8* calcHCT-23 O2 Sat-91
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. Admit to [**Hospital Unit Name 153**] for post op medical management. [**Hospital Unit Name 153**] course as
below. transferred to the floor late in the evening on POD1
2. Geriatric c/s for medical co-management
3. Post-op anemia - POD2 Hct 25.5 -> 1u PRBC, POD3 Hct 24.5,
asymptomatic -> Transfused additional 1u PRBCs. POD5 HCT 24.3
-> 1u PRBCs, POD6 -> HCT 22.6 -> 2u PRBCs
4. Neuro consult for R foot motor deficit - incomplete study,
but no obvious nerve compression.
5. Hematuria and urinary retention - Started on Bactrim
prophylactically. Hematura cleared spontaneously. Patient was
unable to void, straight cathed x many, when urine culture
confirmed negative, stopped Bactrim and foley placed [**7-5**]. Foley
removed [**2148-7-9**] at 6am but patient failed voising trial, bladder
scanned > 400cc after 6 hrs. Foley replaced, increased terazosin
15mg daily, repeat voiding trial [**2148-7-13**] at 6am.
Otherwise, pain was initially controlled with IV pain meds
followed by a transition to oral pain medications on POD#1. The
patient received lovenox for DVT prophylaxis starting on the
morning of POD#1. The surgical dressing was changed on POD#2 and
the surgical incision was found to be clean and intact without
erythema or abnormal drainage. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Mr. [**Known lastname 17922**] is discharged to rehab in stable condition.
[**Hospital Unit Name 13533**]:
74M with DM, HTN, CAD, Parkinson's s/p R TKR experienced low UOP
and AMS in PACU and transferred to MICU. AMS likely secondary to
narcotics, low urine output secondary to under-rescuscitation.
ACUTE ISSUES:
# Anemia: Received 4L crystalloid + 0.5L colloid in the OR
during the procedure. He also received 1 unit PRBCs. He was
given another 1 un PRBCs with lasix upon arrival to the ICU. His
Hct responded appropriately with an increase from 25.2 to 28.8.
# AMS: Pt was very somnolent on arrival but was arousable.
Attributed to a combination of narcotics and underlying
Parkinson's disease. The patient had no focal neurologic
deficits so further imaging of the head was not obtained. He
became significantly more interactive throughout his course and
on transfer was at baseline.
# CAD/hyperlipidemia: Requires antiplatelet therapy s/p stents.
The patient's [**Hospital Unit Name **] and [**Hospital Unit Name 4532**] were restarted after consulting
with orthopedics.
# s/p TKR: Patient was in repositiong device during stay.
Started on Lovenox for DVT prophylaxis.
STABLE ISSUES:
# [**Last Name (un) **]/low UOP: Cr on admission was slightly higher than baseline
(1.3 vs 1.0-1.2). The patient is s/p nephrectomy, which
combined with intraop blood loss probably contributed to his
[**Last Name (un) **]. Urine output responded to lasix
# DM2: Patient was placed back on home insulin at 40 units of
70/30 [**Hospital1 **] and sliding scale. Sugars remained well controlled.
# HTN: SBPs were up to 160s in MICU. The patient was restarted
on home metoprolol dose. His home valsartan and HCTZ were held
pending followup creatinine. Cr remained stable at 1.3 at the
time of transfer.
# Parkinson's: Stable. Continued on home carbidopa-levodopa.
# BPH: Stable, home finasteride and terazosin continued.
TRANSITIONAL ISSUES: F/u outpatient as per ortho.
Medications on Admission:
[**Hospital1 **], diovan, HCTZ, insulin, carbidopa, levodopa, finasteride,
mirtazapine, clopidogrel, pravachol, hytrin, metoprolol
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO once a day as needed for constipation.
13. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 4 weeks: Restart: [**2148-7-10**]
Last dose: [**2148-7-29**].
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day: [**Month (only) 116**] resume 325mg daily after Lovenox completed.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Hold for sedation or confusion.
Disp:*50 Tablet(s)* Refills:*0*
16. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous twice a day: Home dose, but
has been held while inpatient [**2-1**] poor appetite.
17. terazosin 5 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime): Dose increased from 10mg daily [**2-1**] urinary retention.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right knee osteoarthritis
Urinary retention
Post-op anemia due to blood loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out at your follow-up visit in three (3)
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
[**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
visit in three (3) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, and wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment. Left foot AFO at
all times when ambulating.
Physical Therapy:
RLE WBAT
Intensive ROM
CPM 2-3x/day for 2hr sessions, maximum flexion as tolerated
Left foot AFO AAT when ambulating
Mobilize frequently
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice and elevation
TEDs
D/c foley catheter [**2148-7-13**] at 6am and repeat voiding trial
*Staples will be removed at follow-up appointment in 3 weeks*
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2148-7-23**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 31415**]
Date/Time:[**2148-11-12**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2149-2-5**] 4:00
Completed by:[**2148-7-9**]
ICD9 Codes: 5849, 2851, 2930, 2761, 3572, 4280, 2768, 311, 2875, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4721
} | Medical Text: Admission Date: [**2141-12-23**] Discharge Date: [**2142-1-8**]
Date of Birth: [**2080-8-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
central cord syndrome s/p fall
Major Surgical or Invasive Procedure:
ACDF with iliac crest bone graft C4-6
History of Present Illness:
Patient is a 61 y/o M s/p fall forward onto face, no LOC, now
with pain and weakness in RUE and hyperesthesias in BUE.
Past Medical History:
Alcoholism - drinks ~ [**11-25**] pints a day
Physical Exam:
Afebrile
Wound healing well
RUE: [**1-26**] deltoid, biceps, triceps. [**3-28**] WF, WE, FAb, FF
LUE: [**3-28**] deltoid, biceps, triceps, WF, WE, FAb, FF
Sensation: hyperesthesias C5-C7 BUE
BLE: [**3-28**] [**Last Name (un) 938**]/TA/GS
negative clonus, negative hoffmans.
Brief Hospital Course:
The patient was admitted to the floor after evaluation in the
emergency room. He began to undergo DT's prior to surgery, he
was transferred to the SICU and was intubated. He was
subsequently taken to surgery and returned intubated to the
SICU. He was extubated the following day. He continued to be
agitated and was kept and halodol and ativan. Subsequent to his
extubation the ICU team noted that the patient had increasing
trouble swallowing. An MRI was obtained. This showed anterior
hematoma, but no compression on the airway. For safety the
patient was re-intubated. He was extubated when an airleak was
noted around the ET tube. He was discharged to the floor when
stable in the ICU. He was advanced to a regular diet. HE was
dischareged to home once he was able to tolerate a diet, and was
evaluated by physical therapy.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: do not drink alcohol, drive, or operate heavy
machinery while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Central cord syndrome C4-C6
Discharge Condition:
stable
Discharge Instructions:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after this
type of surgery. This should resolve over time. Please take
small bites and eat slowly. Removing the collar while eating
can be helpful ?????? however, please limit your movement of your
neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1352**] in Two weeks. Call his office
at [**Telephone/Fax (1) 1228**] to confirm/schedule your appointment.
Please follow up With Dr [**Last Name (STitle) 11622**] regarding abnormal peripheral
smear.
Completed by:[**2142-1-8**]
ICD9 Codes: 2930, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4722
} | Medical Text: Admission Date: [**2103-11-3**] Discharge Date: [**2103-11-14**]
Date of Birth: [**2054-6-27**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 18074**] is a 49 year old
gentleman who was transferred from [**Hospital6 2561**]
after being struck by a car. The patient had multiple trauma
issues. Earlier that night, prior to be taken to [**Hospital6 18075**], the patient was seen at [**Hospital 8**] Hospital,
where he signed out against medical advice after being
intoxicated. The patient was later struck by a car,
mobilized to Mouth [**Hospital **] Hospital, where he was stabilized
and then transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
Upon arrival to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], the
patient was hemodynamically stable, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma score
of 14. He had a left scalp abrasion, a left clavicle
fracture, a left tibial plateau fracture, a left
superior-inferior pubic rami fracture which was stable, and a
right hemopneumothorax. The patient also suffered an
iatrogenic right subclavian traumatic central line insertion,
which penetrated into his mediastinum at [**Hospital6 **].
PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Hepatitis B
and C. 3. Pancreatitis. 4. Cirrhosis.
MEDICATIONS ON ADMISSION: Serazapine, dose not available.
ALLERGIES: Penicillin and Bactrim.
PHYSICAL EXAMINATION: On physical examination in the
Emergency Room, the patient had a pulse of 108, blood
pressure 138/74, respiratory rate 12 and oxygen saturation
94% on four liters nasal cannula. His [**Location (un) 2611**] coma score was
15. Head, eyes, ears, nose and throat: Scalp abrasion,
extraocular movements intact, pupils equal, round, and
reactive to light and accommodation, oropharynx clear,
trachea midline. Chest: Clear breath sounds, although
diminished in the right chest, left clavicular ecchymosis
with a palpable fracture of the left clavicle.
Cardiovascular: Normal S1 and S2. Abdomen: Soft,
nontender, nondistended, pelvis stable and nontender.
Rectal: No gross blood, guaiac negative with normal
prostate. Extremities: Left lower extremity tender and
swollen although neither thigh nor calf were tight; bilateral
dorsalis pedis and posterior tibialis pulses.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit, where he remained stable. On [**2103-11-8**], he underwent an open reduction and internal
fixation of his left tibial plateau fracture by orthopedic
surgery. The patient tolerated the procedure well and was
returned to the Surgical Intensive Care Unit, where he
continued to do well.
Complicating the [**Hospital 228**] hospital course was that the
patient was withdrawing from alcohol and suffering from
delirium tremens. He was therefore placed on a CIWA protocol
schedule. The patient continued to do well in the Surgical
Intensive Care Unit and was transferred to the floor, where
he remained stable. The patient was able to tolerate orals
without any difficulty. His chest tube was removed without
any difficulty.
Psychiatry was consulted for suicidal ideation. The was
given a sitter, who remained with him at all times. He
continued to improve from a surgical standpoint and was ready
for discharge on [**2103-11-12**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 18076**]
MEDQUIST36
D: [**2103-11-12**] 09:19
T: [**2103-11-12**] 10:08
JOB#: [**Job Number 18077**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4723
} | Medical Text: Admission Date: [**2120-3-17**] Discharge Date: [**2120-3-19**]
Date of Birth: [**2059-4-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
etoh intoxication
Major Surgical or Invasive Procedure:
Femoral line placement
History of Present Illness:
60M w/ hx of EtOH (hx of DTs, seizures), lung cancer, who was
admitted to the ED for etoh intoxication. He then triggered for
hypoxia. Initially 87% on RA with good pleth. Hr was 104, BP
114/74. Placed on NRB with SaO2 98%. Pt was weaned off of O2 and
is 89-92% on 2L and improves to 92-94% on 4L. Pt would not allow
care and was obviously drunk so was given a dose of Haldol. He
then was shaky and received 3 mg total of ativan in the ED.
.
Pt does not endorse a hx of COPD but says he has lung CA. In
[**2114**], pt presented similarly to the ED and had a CTA at that
time neg for PE but w/ spiculated masses. Pt was also treated
with withdrawal at that time. In the ED, they attempted to
obtain peripheral access but were unable to, so a femoral line
was place. He could not get a CTA because there were no PIVs. He
was given one dose of lovenox in the ED. He also fell in the
emergency room on his buttock but did not hit his head. No
further imaging was done at that time. He received 3L of NS in
the ED.
.
On arrival to the floor, the patient is tachycardic to 108, BP
180/81, R 20 and 99% on 4L. He is unable to provide a history.
He seems intoxicated. He says he does not drink, do drugs or
smoke, though. In the ED note, it says that he stated he drank
vodka tonight. He does not know where he is. He is tremulous and
aggitated.
.
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:
1. EtOH abuse (distant history; 11 year sober period; recent 18
month binge); history of DT's and seizures.
2. Adenocarcinoma x 12 years
3. Depression
Social History:
Patient currently lives with a roommate, previously homeless,
receives SSI financial support. Has an ex-wife and 2 daughters
(in college) who he is not in touch with when he drinks (no
contact for past 2 years). Says he only uses EtOH and
cigaretttes. Denies any other IV or other drug use.
Family History:
Noncontributory
Physical Exam:
Vitals: T:afebrile, BP: 151/75, P: 106, R:18, O2: 94% on 4L
General: dishevled, mumbling, no acute distress but aggitated
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchorous throughout but patient was snoring and not
cooperating with exam, no wheezes heard
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2120-3-16**] 11:00PM BLOOD WBC-10.7 RBC-4.50* Hgb-13.0* Hct-39.0*
MCV-87# MCH-29.0 MCHC-33.4 RDW-15.6* Plt Ct-237
[**2120-3-17**] 05:09AM BLOOD WBC-12.0* RBC-4.07* Hgb-11.8* Hct-35.3*
MCV-87 MCH-29.0 MCHC-33.4 RDW-15.7* Plt Ct-232
[**2120-3-18**] 05:00AM BLOOD WBC-9.1 RBC-4.21* Hgb-12.7* Hct-36.6*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.3 Plt Ct-252
[**2120-3-19**] 02:07AM BLOOD WBC-7.5 RBC-4.35* Hgb-12.4* Hct-37.2*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.2 Plt Ct-251
[**2120-3-16**] 11:00PM BLOOD Neuts-75.1* Lymphs-19.1 Monos-5.0 Eos-0.5
Baso-0.3
[**2120-3-16**] 11:00PM BLOOD Plt Ct-237
[**2120-3-17**] 05:09AM BLOOD PT-12.2 PTT-30.6 INR(PT)-1.0
[**2120-3-18**] 05:00AM BLOOD PT-12.2 PTT-24.8 INR(PT)-1.0
[**2120-3-18**] 05:00AM BLOOD Plt Ct-252
[**2120-3-19**] 02:07AM BLOOD PT-11.5 PTT-25.8 INR(PT)-1.0
[**2120-3-19**] 02:07AM BLOOD Plt Ct-251
[**2120-3-16**] 11:00PM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-142
K-4.0 Cl-98 HCO3-30 AnGap-18
[**2120-3-17**] 05:09AM BLOOD Glucose-74 UreaN-9 Creat-0.6 Na-140 K-3.8
Cl-98 HCO3-29 AnGap-17
[**2120-3-18**] 05:00AM BLOOD Glucose-121* UreaN-4* Creat-0.5 Na-136
K-3.3 Cl-97 HCO3-32 AnGap-10
[**2120-3-19**] 02:07AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-135 K-3.8
Cl-99 HCO3-27 AnGap-13
[**2120-3-16**] 11:00PM BLOOD ALT-55* AST-55* LD(LDH)-235 AlkPhos-78
TotBili-0.3
[**2120-3-17**] 05:09AM BLOOD ALT-49* AST-52* AlkPhos-72 TotBili-0.4
[**2120-3-16**] 11:00PM BLOOD Lipase-44
[**2120-3-16**] 11:00PM BLOOD Calcium-8.6 Phos-2.7# Mg-1.9
[**2120-3-17**] 05:09AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.7
[**2120-3-18**] 05:00AM BLOOD Calcium-8.4 Phos-1.7* Mg-2.3
[**2120-3-19**] 02:07AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.9
[**2120-3-16**] 11:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2120-3-17**] 05:09AM BLOOD ASA-NEG Ethanol-143* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2120-3-16**] 11:18PM BLOOD D-Dimer-1721*
[**2120-3-16**] 11:05PM BLOOD Lactate-3.1*
CXR: IMPRESSION: Mild hilar prominence which appears stable
compared with multiple
prior studies. Findings may be due to pulmonary arterial HTN.
Recommend
clinical correlation.
Brief Hospital Course:
60 y/o M with hx of lung adenocarcinoma and etoh abuse who
presents intoxicated and hypoxemic.
# ETOH intoxication/withdrawl: Presented actively intoxicated.
Active signs of withdrawal on exam. Treated with valium prn per
CIWA scale. CIWAs came down and patient appeared more
comfortable across his admission. His outpatient psychiatrist,
Dr, [**Name (NI) 69234**], met with him during his admission as well as
physicians from health care for the homeless. Per their
discussions with him he agreed that if he left AMA he would
follow up with him tomorrow and arrange to be admitted to
[**Doctor Last Name **] house for further treatment. Social work and psychiatry
were consulted and various forms of assistance were offered.
# Hypoxia: unclear etiology at this time; likely is secondary to
underlying lung cancer or COPD. No apparent respiratory
distress. Was easily weaned from 4 to 2LNC and then to RA. PE
was on the differential as his d-dimer was elevated and he has a
hx of cancer however tachycardia and hypoxia have now resolved
and likelihood of PE overall seems low. Was given lovenox in the
ED but this was then held given low probability.
# Unsteady gait: likely from etoh use. PT was planned for after
pt finished withdrawing however pt left AMA prior to this.
# Anemia: mild, slightly below baseline but has been that low
before.
# Access: Initially a femoral line was placed, which was later
replaced with a midline line.
# AMA Discharge: Pt verbalized his desire to leave the hospital
to address some concerns at home prior to being admitted for
further treatment of his alcohol withdrawal and dependence.
Signed out AMA with plan for admission to [**Doctor Last Name **] house on the
following day, as above.
Medications on Admission:
none
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with alchohol intoxication. You are being
discharged to home at your request which is against medical
advice. You have agreed to see your physician tomorrow and be
admitted to the McGuinnis House for further treatment.
Please refrain from drinking. Please take all of your previous
medications as prescribed.
Followup Instructions:
Please arrange to see your physician [**Name Initial (PRE) 503**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 496, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4724
} | Medical Text: Admission Date: [**2120-10-29**] Discharge Date: [**2120-12-2**]
Date of Birth: [**2073-9-6**] Sex: M
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old
male with a history of a stab wound to the left chest and to
the left back and the left flank on [**2120-6-16**]. At that time
he had undergone a right thoracoscopy and a left
thoracoscopy and an exploratory laparotomy on [**2120-7-8**]
when he was found to have a hematoma of the transverse
mesocolon of the splenic flexure. Because of his unstable
state the patient was taken to the Surgical Intensive Care
Unit after stabilizing the hematoma controlling the bleeding
and was taken back to the Operating Room for closure of his
abdomen on [**2120-7-10**]. The patient subsequently was found
to have an ischemic splenic flexure of the colon on [**2120-7-17**] and underwent a segmental colectomy at the splenic
flexure and the transverse colostomy with [**Doctor Last Name 3379**] pouch.
the patient subsequently underwent a right colectomy and
ileostomy after the becoming septic and was found to have a
right colonic infarction on [**2120-8-9**]. The patient was
discharged and underwent an elective reversal ileostomy and
ileocolostomy with side to side anastomosis and lysis of
adhesions on [**2120-10-18**]. The patient was discharged
after that surgery and is now admitted to [**Hospital1 346**] on [**2120-10-29**] after having
thought to have elevated white blood cell count and abdominal
pain when he presented to an outside hospital Emergency
Department.
PAST SURGICAL HISTORY: Significant as mentioned above.
PAST MEDICAL HISTORY: Significant for anxiety.
SOCIAL HISTORY: The patient drinks a half a pint of Vodka
three times a month usually associated with his stress
attacks. The patient is a smoker averaging about one pack
per day for thirty years. The patient denies any intravenous
or illicit drug use. He is reportedly homeless and sleeps on
the street or shelters or occasionally at his sister's place.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Combivent inhaler.
2. Ativan 0.5 mg po q 6 hours prn.
3. Oxycodone 5 to 10 mg po q 4 hours prn.
4. Tylenol.
5. Ibuprofen.
6. One can of Boost at each meal.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
at 99.6. Heart rate of 82. Blood pressure 128/60.
Respiratory rate 18. O2 sat 100% on room air. Potassium
4.9. The patient was alert and oriented times three in
moderate distress secondary to pain. Alkaline phosphatase
was 54. HEENT normocephalic, atraumatic head. Supple neck.
Normal examination of the oropharynx unchanged from prior
admission. Cardiovascular examination regular rate and
rhythm. S1 and S2 without any murmurs. Respirations clear
to auscultation bilaterally. No crackles, wheezes or
rhonchi. Abdominal examination the patient was with good
bowel sounds, soft, but very tender to palpation
throughout the abdomen. There was no rebound appreciated.
The abdominal wounds were clean, dry and intact without any
erythema or tenderness focal to the incision. The peripheral
examinations were with good palpable pulses.
HOSPITAL COURSE: his significant abdominal examination the
patient was started on Ampicillin, Levofloxacin and Flagyl.
The patient was made NPO and he was supported with
intravenous fluids. On hospital day two the patient
underwent a CT of the abdomen and pelvis, which showed an
intraabdominal fluid collection with enhancing room
throughout the peritoneal cavity, which was found to connect
up with a small pocket of fluid adjacent to the ileocolic
anastomotic site and mid pelvis. There was also gas noted
within the small pocket of fluid and this was interpreted to
be consistent with an intraabdominal abscess and a possible
anastomotic leak. There was no evidence of bowel wall
thickening and no evidence of obstruction at that time. The
patient started developing a fever of a temperature max of
102.5 despite being on intravenous antibiotics with an
unchanged abdominal examination. Therefore the patient
underwent a CT guided drainage of the abscess on hospital day
three removing approximately 10 cc of purulent substance on
initial insertion and the patient received a pigtail catheter
in the right lower quadrant. After the procedure the patient
was continued on intravenous antibiotics Ampicillin,
Levofloxacin and Flagyl and continued to receive intravenous
fluids. The patient was noted to have declining urine output
requiring more then 6 liters of intravenous fluid
resuscitation. The patient became tachycardic and on
laboratory examination the patient was found to have decrease
in hematocrit from 32.4 to 21.8 over the course of 11 hours.
The patient was also found to be thrombocytopenic with a
platelet count down to 49 and a rise in creatinine to 2.3.
Given these conditions the patient was thought to underwent
an active intraabdominal bleeding or having sepsis with
coagulopathy. The patient was urgently transferred to the
Trauma Surgical Intensive Care Unit for close monitoring. The
patient was monitored with serial hematocrit checks and was
transfused packed red blood cells and platelets as needed.
The patient underwent a repeat CAT scan of the abdomen and
was found to have a new collection in the upper abdominal
area, which contained air and extravasated barium. The
pigtail catheter was inserted into this new area of abscess
removing approximately 20 cc of thick viscous brown liquid.
Subsequent to the second CT guided drainage the patient
returned to the Surgical Intensive Care Unit, but
progressively became dyspneic and was having respiratory
difficulty. The patient was intubated on [**2120-11-4**]
and was urgently taken to the Operating Room for exploratory
laparotomy. On [**2120-11-4**] the patient successfully
underwent drainage of the intraabdominal abscesses, lysis of
adhesions and a creation of a loop ileostomy. Please see the
operative report for further details. The patient left the
Operating Room in critical condition, intubated and returned
to the Trauma Surgical Intensive Care Unit with three JP
drains and continued on intravenous antibiotics including
Vancomycin, Ceftriaxone, Flagyl and Fluconazole.
Preoperatively the patient's creatinine values were rising
and by postoperative day one they were even higher to a value
of 4.2. The patient was seen by Renal Consult Service,
calculated fraction excretion of sodium (FENA) was 1.9%. The
patient's urine was shown to have many granular and muddy
brown casts with proteinuria and hematuria, all the finding,
which were consistent with acute renal failure and acute
tubular necrosis. For management of this intravascular and
extravascular volume the patient underwent hemodialysis.
Postoperatively, the patient was also started on total
parenteral nutrition with minimal volume and a low protein
given his acute renal failure.
With respect to his respiratory system the patient was
intubated and was on the ventilator machine and was able to
tolerate a CPAP with pressure support by postoperative day
three and was successfully extubated on postoperative day
four. The patient was on Ampicillin and Levofloxacin
preoperatively and postoperatively the patient was on
Vancomycin and Ceftriaxone, Flagyl and Fluconazole. The
abscess drainage from [**10-31**] grew out pan sensitive
enterococcus eventually. The second CT guided drainage of
the abscess grew out Levofloxacin resistant enterococcus and
Ceptaz and Cipro resistant Pseudomonas and staph aureus that
was resistant to Levaquin and Penicillin, but sensitive to
Vancomycin. Postoperatively, the patient also started
developing infection of his pulmonary system with his sputum
cultures growing out Pseudomonas. Ceftriaxone was changed to
Meropenem and the patient was continued on Vancomycin,
Meropenem, Flagyl and Fluconazole for treatment of his
Pseudomonas pneumonia and intraabdominal infection.
Unfortunately the sputum cultures subsequently grew out
Pseudomonas, but became resistant to Meropenem. However,
remained sensitive to Zosyn. When the sensitivities returned
as previously mentioned the patient was taken off the
Meropenem and started on Zosyn and continued on Vancomycin.
Nutritionally the patient s continued on total parenteral
nutrition, but was also started on tube _______ via Dobbhoff
tube and was doing relatively well until postoperative day 14
when he was found to have respiratory distress requiring
greater O2 to support him. There was a suspicion that the
patient might have had an aspiration pneumonia and the
patient was reintubated and was put on the ventilator
machine. Sputum cultures taken again after reintubation
showed moderate growth Pseudomonas with resistance to Cipro
and Meropenem and sensitive to Zosyn. A bronchoscopy and
bronchoalveolar lavage also revealed same Pseudomonas.
Complicating this Pseudomonas ventilator related pneumonia
was the fact the patient was fluid overloaded and was
requiring diuresis. However, given his acute renal failure
the patient was requiring hemodialysis with treatment with
Zosyn for which the Pseudomonas was sensitive to and
resolution of his congestive heart failure. The patient's
respiratory status improved and the patient was successfully
extubated on postoperative day 20. The patient continued to
do well with gradual resolution of his acute renal failure
and acute tubular necrosis and was transferred to the regular
floor on postoperative day 23. The patient continued on
intravenous Zosyn for completion of antibiotic treatment and
was monitored for his renal functions. The patient underwent
a speech and swallow evaluation given his risk for aspiration
and was cleared to continue on his po intake and the
patient's nutritional needs were assessed by caloric count
and the patient was found to be taking adequate po and his
nutritional intake was supplemented with Boost plus
nutritional supplements three times a day. The patient was
seen by physical therapy while he was on the floor regarding
his deconditioning and was recommended to be discharged to
rehab for improvement of his physical functioning. By
postoperative day 28 the patient was ready for discharge.
It should be noted that the patient should be followed up
closely regarding his renal function given his creatinine
volume of 1.4 on discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to rehab.
DISCHARGE DIAGNOSES:
1. Status post stab wounds to the left chest and to the left
back and left flank.
2. Status post exploratory laparotomy for massive hematoma
of the transverse mesocolon splenic flexure.
3. Status post closure of the abdomen.
4. Status post transverse colostomy, [**Doctor Last Name 3379**] pouch and
segmental colectomy.
5. Status post right colectomy and ileostomy for right
colonic infarction.
4. Status post reversal of ileostomy.
5. Status post exploratory laparotomy on [**2120-11-4**]
for drainage of intraabdominal abscess.
6. Sepsis subsequent to the intraabdominal abscess and
ventilatory associated Pseudomonas.
7. Pneumonia.
8. Respiratory failure resolved.
9. Acute renal failure with acute tubular necrosis resolving
with creatinine value of 1.4 on discharge.
DISCHARGE MEDICATIONS:
1. Combivent inhaler one to two puffs inhaled q 6 hours prn.
2. Ativan 0.5 mg po q 8 hours prn.
3. Ultram 100 mg po q 4 to 6 hours prn.
4. Tylenol 325 to 650 mg po q 4 to 6 hours prn.
5. Imodium 2 mg po b.i.d.
6. Heparin 5000 units subq q 12 hours.
7. Benadryl 25 mg po q.h.s. prn insomnia.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 519**] in one
to two weeks after discharge. Please call his office for an
appointment date and time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2120-12-2**] 08:29
T: [**2120-12-2**] 08:44
JOB#: [**Job Number 48188**]
ICD9 Codes: 0389, 5845, 5070, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4725
} | Medical Text: Admission Date: [**2111-10-6**] Discharge Date: [**2111-10-11**]
Date of Birth: [**2049-3-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2111-10-6**] - CABGX3 (Left internal mammary->Left anterior
descending artery, Saphenous vein graft to Obtuse marginal
artery and saphenous vein graft to posterior descending artery.)
History of Present Illness:
62 year old gentleman with h/o esophageal adenocarcinoma s/p
transhiatal esophagectomy in [**2-6**]. He has had recurrent angina
which prompted an ETT which was positive. A cardiac cath was
performed which showed severe three vessel disease. He was
subsequently refered for surgical revascularization.
Past Medical History:
GERD, hypertension, and orally controlled diabetes, esophageal
adenocarcinoma, Renal artery stenosis, neuropathy
Social History:
He works as an electrician and has a remote 20-pack-year smoking
history. He
quit drinking one year ago, but drank a 6-pack of beer per week
prior to that.
Family History:
Noncontributory
Physical Exam:
VS: 98.9, 135/87, 91SR, 18, 96%RA
Gen: NAD, [**Male First Name (un) 4746**]
Pulm: LCTAB
CV: RRR, no murmur or rub
abd: NABS, soft, non-tender, non-distended
Ext: warm, trace edema
Incisions: [**Doctor Last Name **]- c/d/i, no erythema or drainage, sternum
stable,
EVH- c/d/i, no erythema or drainage
Neuro- non-focal
Pertinent Results:
[**2111-10-10**] 07:45AM BLOOD WBC-6.9 RBC-2.92* Hgb-9.1* Hct-25.1*
MCV-86 MCH-31.3 MCHC-36.3* RDW-14.6 Plt Ct-190
[**2111-10-11**] 06:50AM BLOOD Hct-28.5*
[**2111-10-10**] 07:45AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-135
K-3.4 Cl-103 HCO3-26 AnGap-9
[**2111-10-11**] 06:50AM BLOOD K-4.2
[**2111-10-10**] 07:45AM BLOOD Mg-2.2
CXR
[**Known lastname **],[**Known firstname **] E [**Medical Record Number 71079**] M 62 [**2049-3-13**]
Radiology Report CHEST (PA & LAT) Study Date of [**2111-10-10**] 8:28 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2111-10-10**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 71080**]
Reason: infiltrate
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p CABG x3
REASON FOR THIS EXAMINATION:
infiltrate
Final Report
CHEST PA AND LATERAL
REASON FOR EXAM: Status post CABG.
Since yesterday, bilateral pleural effusions, more marked on the
left,
slightly increased. Minimal left apical pneumothorax is
unchanged.
Retrosternal area is unchanged, likely postoperative. Left
retrocardiac
atelectasis is also unchanged. The cardiomediastinal silhouette
and hilar
contours are otherwise unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SAT [**2111-10-10**] 12:04 PM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname 71037**] was admitted to the [**Hospital1 18**] on [**2111-10-6**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypas grafting
to three vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. On postoperative day one, 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. Chest tubes and pacing
wires were discontinued without complication. Hospital course
was uneventful. By the time of discharge on POD 5, the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics.
Medications on Admission:
lopressor 200', metformin 500', nifediac 90', protonix 40",
simvastatin 10', erythromycin 400"', imdur 30', lisinopril 10'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. 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*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
9. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours).
Disp:*240 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
CAD s/p CABGx3
HTN
GERD
Esophageal adnocarcinoma and is s/p esophagectomy
Diabetes
Renal artery stenosis
Hyperlipidemia
Neuropathy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 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:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr.[**Last Name (STitle) 27945**] in 1 week ([**Telephone/Fax (1) 54195**]) please call for appointment
Dr. [**Last Name (STitle) **] [**1-4**] weeks () please call for appointment
Completed by:[**2111-10-11**]
ICD9 Codes: 4111, 4019, 2720, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4726
} | Medical Text: Admission Date: [**2152-3-28**] Discharge Date: [**2152-4-10**]
Date of Birth: [**2072-7-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Cough and difficulty breathing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79F with history of hypertension, osteoporosis and 3+ Mitral
valve regurgitation who presented to [**Company 191**] today with 1 week of
productive cough at home (husband sick with similar illness), no
fevers but lots of green sputum. One week ago the patient went
to her PCP for her yearly physical and was completely well. At
[**Company 191**] today and was found to be hypoxic to 84% on RA and CXR
showed a left sided pleural effusion. She was also noted to be
tachycardic with an irregular rhythm and EKG showed afib (no
prior history) so the patient was instructed to go to the ED.
In the ED, initial vs were: 98.9 80 128/79 20 94% 6L. Then
tachy into 150s, EKG showed Afib w/ RVR. Labs notable WBC of 9
but 32% bands, sodium 130, creatinine of 1.9 and Lactate 3.4.
U/A was negative. Patient was given ceftriaxone and azithromycin
and 2.7L IVF. After the fluids, the patient became more hypoxic
to 85% and appeared to flash. Gave 20 IV lasix, 20 IV dilt, then
on a dilt drip, on bipap. RR came down from 44 to 28-32. Bipap
[**7-9**]. Patient is full code.
On arrival to the MICU, patient reports she feels somewhat
better. She was taken off of bipap and put on a NRB but became
more tachypneic so was put back on bipap. Bedside ultrasound
showed small pleural fluid on the left side.
Past Medical History:
Osteoporosis
Mitral valve prolapse with 3+ MR. Moderate secondary pulmonary
hypertension.
S/P TAH for leiomyoma [**2108**].
Cyst on back removed in [**2103**].
S/P tonsillectomy.
Episode of shingles.
Breast fibroadenoma left, [**2137**].
Social History:
She is a retired Professor of writing at [**State 17405**], [**Location (un) 86**]. She does not smoke. Moderate alcohol
consumption, no more than two glasses of wine. Lives with her
husband. 20 pack years smoking history. Quit smoking 40 years
ago.
Family History:
Father died of congestive heart failure in his 70's. Mother
died of congestive heart failure at age 88. She is married with
three stepchildren and four grandchildren.
Physical Exam:
PHYSICAL EXAM ON ARRIVAL ON THE MEDICINE FLOOR:
Vitals: T: 97.3 BP: 117/58 P: 96 R: 18 O2: 94% 4L NC
General: Elderly woman sitting upright in hospital bed,
pleasant, alert, oriented, and breathing comfortably with NC.
Occasional coughing.
HEENT: PERRL, EOMI, sclera anicteric, mucus membranes moist,
oropharynx clear without erythema or exudates
Neck: Supple, no LAD or thyromegaly appreciated
Lungs: Coarse breath sounds throughout without appreciable
wheezes. Fair air movement.
CV: Irregular rhythm, normal S1 + S2, II/VI holosystolic murmur
best heard at the apex.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly appreciated
Ext: Cool, 2+ dorsalis pedis pulses bilaterally, no clubbing,
cyanosis or edema
PHYSICAL EXAM ON DISCHARGE:
Vitals: T: 98.6 BP: 110/70 P: 82 R: 20 O2: 94%
General: Elderly woman sitting upright in her chair, pleasant,
talkative, and breathing comfortably on room air
HEENT: PERRL, EOMI, mucus membranes moist
Neck: Supple
Lungs: Crackles heard at the left lower throughout. Left greater
than right crackles at the bases, withhout appreciable wheezes.
CV: Irregular rhythm, normal S1 + S2, harsh II/VI holosystolic
murmur best heard at the apex.
Abdomen: Soft, non-tender, non-distended
Ext: Warm and well-perfused, no clubbing, cyanosis or edema
Pertinent Results:
LABS ON ADMISSION:
[**2152-3-28**] 06:58PM BLOOD WBC-9.4# RBC-4.09* Hgb-13.0 Hct-38.4
MCV-94 MCH-31.8 MCHC-33.9 RDW-12.0 Plt Ct-488*
[**2152-3-30**] 03:57AM BLOOD WBC-17.0*# RBC-3.73* Hgb-11.9* Hct-35.3*
MCV-95 MCH-31.9 MCHC-33.6 RDW-12.1 Plt Ct-464*
[**2152-3-28**] 06:58PM BLOOD Neuts-50 Bands-32* Lymphs-10* Monos-7
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2152-3-29**] 04:34AM BLOOD Neuts-65 Bands-16* Lymphs-10* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2152-3-30**] 03:57AM BLOOD Neuts-81* Bands-3 Lymphs-6* Monos-7 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2152-3-28**] 06:58PM BLOOD Glucose-170* UreaN-53* Creat-1.9*#
Na-130* K-5.1 Cl-93* HCO3-24 AnGap-18
[**2152-3-29**] 04:34AM BLOOD Glucose-127* UreaN-43* Creat-1.2* Na-133
K-4.0 Cl-100 HCO3-22 AnGap-15
[**2152-3-30**] 03:57AM BLOOD Glucose-120* UreaN-26* Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-25 AnGap-13
[**2152-3-28**] 06:58PM BLOOD CK-MB-4 proBNP-9794*
[**2152-3-28**] 06:58PM BLOOD cTropnT-0.04*
[**2152-3-29**] 04:34AM BLOOD CK-MB-6 cTropnT-0.02*
[**2152-3-28**] 06:58PM BLOOD Osmolal-289
[**2152-3-28**] 06:58PM BLOOD TSH-0.69
[**2152-3-28**] 07:05PM BLOOD Lactate-3.4*
URINE CULTURE (Final [**2152-3-30**]): <10,000 organisms/ml.
[**2152-3-29**] Legionella Urinary Antigen NEGATIVE FOR LEGIONELLA
SEROGROUP 1 ANTIGEN.
LABS ON DISCHARGE:
[**2152-4-10**]
WBC 15.6, Hb 10.1, Hct 30.1, Plt 1011
PMN 86.6, Lymphs 9.5, Monos 2.8, Eos 0.9, Baso 0.2
Na 138/K 4.5, Cl 105/HCO3 26, BUN 17/Cr 0.6, Glu 101
Ca 8.4, Mg 1.9, P 3.8
PT 18.0, INR 1.6
Dig 0.8
RELEVANT IMAGING:
[**2152-3-28**] CXR (on admission): Left lower lobe atelectasis and left
pleural effusion; given the possible history of smoking, an
obstructive neoplasm at the left hilum causing left lower lobe
atelectasis and effusion cannot be excluded on this radiograph
and is best further evaluated with a chest CT.
[**2152-4-8**] CXR (on discharge): There is background COPD with
diffuse parenchymal scarring. The cardiomediastinal silhouette
is enlarged, though partially obscured on the left by a
moderate-sized pleural effusion and underlying collapse and/or
consolidation. There is also a small right pleural effusion,
with underlying collapse and/or consolidation. Doubt CHF.
Compared with [**2152-4-6**], 15:38, the left-sided effusion is larger.
Otherwise, I doubt significant change. Patchy opacities
throughout both lungs may represent parenchymal scarring due to
background COPD, but the possibility of a superimposed patchy
interstitial process cannot be entirely excluded. (The
appearance is similar to a film dated [**2152-3-31**], at which time it
was thought to represent extensive multifocal pneumonia.)
[**2152-3-31**] CT CHEST W&W/O CONTRAST:
1. No evidence of pulmonary embolism.
2. Extensive multifocal pneumonia, worse in the left lower lobe.
3. Bilateral nonhemorrhagic mild-to-moderate pleural effusions,
predominantly subpulmonic.
4. Bilateral reactive hilar adenopathy.
5. Mild dilatation of the aortic root.
[**2152-3-30**] [**Month/Day/Year **]: Hyperdynamic left ventricular systolic
function. Moderate to severe anterior mitral valve leaflet
prolapse with moderate mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2151-11-15**],
the left ventricular systolic function is now hyperdynamic
(previously normal). The severity of mitral regurgitation and
tricuspid regurgitation appear to have decreased somewhat,
although the overall image quality is worse on the current
study. The ascending aorta and descending thoracic aorta are now
dilated.
[**2152-4-3**] [**Month/Day/Year **] WITH SALINE: No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 79 year old previously healthy woman with a
history of controlled hypertension and 3+ mitral valve
regurgitation who was admitted to the hospital for multifocal
pneumonia and new onset atrial fibrillation with rapid
ventricular response to the 150s, requiring a stay in the
medical intensive care unit before transfer to the medical
floor.
BRIEF HOSPITAL COURSE BY PROBLEM:
# MULTIFOCAL PNEUMONIA: The patient was admitted for hypoxic
respiratory failure with O2sats 84% on room air. Chest x-ray
showed left lower lobe consolidation and effusion. She was given
3L of intravenous fluids in the ED, and her oxygenation acutely
worsened, requiring BiPap and transfer to the medical intensive
care unit. Repeat CXR was consistent with acute volume overload
(see below). Lung ultrasound was not concerning for empyema or
parapneumonic effusion. Ceftriaxone and Azithromycin were
started for community acquired pneumonia. Legionella urinary
antigen was negative. The patient had persistently elevated A-a
gradients on hospital days [**11-29**], so a CT scan was done to rule
out a pulmonary embolus. This was negative. Given the patient's
lack of improvement and ongoing leukocytosis with bandemia, her
antibiotics were broadened to Vancomycin, Cefepime, and
Levofloxacin. She completed an 8 day course on [**2152-4-3**]. Her
respiratory status improved, and she was transferred to the
medicine floor. Persistent leukocytosis on [**2152-4-8**] prompted a
repeat CXR, which showed continued bilateral pulmonary effusion
(L>R). Interventional pulmonology performed a thoracentesis for
concern of a paraneumonic effusion. The pleural fluid was
borderline exudative by Light's Criteria with negative
cytologies and cultures. Interventional pulmonology felt that
there would be little benefit from further interventions. She
continued to improve, and was weaned to room air. Her ambulatory
oxygen saturations were above 90% on room air. She was
discharged to home with VNA follow up for O2sat checks.
# ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE: The
patient has no prior history of atrial fibrillation. In the ED,
the patient was found to be in AFib with RVR to the 150s. She
was immediately started on diltazem gtt and loaded with digoxin
for rate control. She was transitioned to PO diltiazem and
continued on digoxin. Her heart rate remained stable in the
90s-100s. Echocardiography with bubble study did not show any
changes to the mitral valve and was negative for intracardiac
and extracardiac shunt. Her TSH was within normal limits. The
patient was started on coumadin for stroke prevention given a
CHADS2 score of 2. (Her insurance would not cover Dabigitran).
Ultimately, her new onset atrial fibrillation with RVR was
thought to be related to her multifocal pneumonia and mitral
valvular disease. The patient should follow up with her
cardiologist and undergo transesophageal [**Date Range 461**] as
recommended by cardiology.
# ACUTE SYSTOLIC CONGESTIVE HEART FAILURE: In the setting of
volume resuscitation, the patient's new atrial fibrillation with
RVR and her underlying mitral valve regurgitation led to acute
systolic congestive heart failure with flash pulmonary edema.
Her initial EKG showed ST depressions that appeared to be rate
related. Acute coronary syndrome was unlikely as three sets of
cardiac enzymes were within normal limits. She was diuresed with
IV lasix, and her respiratory status improved.
# ACUTE KIDNEY INJURY: The patient's creatinine on admission was
1.9 (baseline 0.5-0.6). The etiology was thought to be
multifactorial, related both to intravascular volume depletion
in the setting of acute systolic congestive heart failure and
poor PO intake given her illness. Her creatinine improved with
diuresis. Her home lisinopril was held and not restarted on
discharge given systolic blood pressures in the 90s-110s. When
stable, lisinopril can be restarted as an outpatient.
# PERSISTENT LEUKOCYTOSIS: The patient had persistent
leukocytosis, prompting an additional workup for alternative
infections. Urine and blood cultures were repeatedly negative.
CXR on [**2152-4-8**] prompted the thoracentesis described above. C.
diff was negative x 3. Ultimately, the persistent leukocytosis
was attributed to a stress response. The patient's WBCs should
be trended as an outpatient.
# THROMBOCYTOSIS: The patient's platelets continued to rise,
reaching 1011 on the day of discharge. This was thought to be a
reactive thrombocytosis given the patient's recent infection.
Her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], was contact[**Name (NI) **] about
starting aspirin, and we elected not to start aspirin at this
time given risk of bleeding wtih her new coumadin as well. Her
platelet counts will be followed as an outpatient.
# HYPONATREMIA: The patient was initially hyponatremic, which
resolved on the second day of hospitalization. This was likely
due to SIADH in the setting of her pulmonary processes and/or
intravascular volume depletion in the setting of her acute
systolic congestive heart failure and poor PO intake.
# CONTROLLED HYPERTENSION: Prior to admission, the patient took
lisinopril for blood pressure control. This medication was held
in the setting of her acute kidney injury and subsequent
systolic blood pressures in the 90s-110s from the initiation of
diltiazem. Lisinopril was not started on discharge but may be
restarted as an outpatient.
# OSTEOPOROSIS: Restarted home calcium and vitamin D once she
was taking POs.
# DECONDITIONING: Due to her hospital stay, she felt "weak." She
worked with physical therapy and was able to ambulate without
assist with oxygen saturations above 90% on room air.
TRANSITIONS OF CARE:
- WBCs and platelets should be followed as an outpatient.
- INR should be monitored for appropriate coumadin dosing. This
has been arranged at the [**Hospital 191**] [**Hospital **] clinic.
- Lisinopril was not restarted given SBPs 90s-110s. Consider
restarting as an outpatient.
- Pt should get scripts for 2.5 mg of coumadin as well at her
follow up appointment for ease of dosing per the [**Hospital **]
clinic.
Medications on Admission:
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 tsp by mouth
tid prn cough 6 oz.
CONJUGATED ESTROGENS [PREMARIN] - 0.3 mg Tablet - 1 Tablet(s) by
mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg-400
unit Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
5. Premarin 0.3 mg Tablet Sig: One (1) Tablet PO once a day.
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnoses:
Multifocal pneumonia
Atrial fibrillation with rapid ventricular response
Mitral valve prolapse
Mitral regurgitation
Acute kidney injury
Secondary diagnoses:
Osteoporosis
Hypertension, controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you had difficulty
breathing. A chest x-ray was performed, which showed that you
had pneumonia in multiple places in your lungs. This was later
confirmed with a CT scan. You were initially taken to the
medical intensive care unit and required special masks to help
you breathe. You were also given a combination of antibiotics
for an 8 day course, and your breathing improved over time. You
were transferred from the intensive care unit to the medical
floor, where you received additional physical therapy to help
you improve your strength. Your oxygen requirements have
decreased since you have been in the hospital. You were able to
walk without oxygen, and the oxygen levels in your blood
remained appropriate.
During your hospitalization, you were also found to have atrial
fibrillation, an irregular heart beat pattern. Your heart rate
was initially very fast, so you were given medicines to slow
your heart rate down. You will continue to take the digoxin and
metoprolol as directed when you leave the hospital. You were
also started on coumadin to make your blood less likely to clot
and to decrease the risk of stroke related to clotting that can
occur in people with atrial fibrillation. You will also continue
to take coumadin as directed and have your blood drawn to make
sure that your INR (a measure of anti-coagulation) is within the
appropriate range.
You had an [**Location (un) 461**] of your heart while you were in the
hospital. An [**Location (un) 461**] is an ultra-sound picture of the way
that your heart beats. It showed that you have mitral valve
prolapse and mitral valve regurgitation. This means that the
mitral valve in your heart does not close all the way, so some
blood leaks through. Please follow up with your cardiologist,
Dr. [**Last Name (STitle) 171**], as listed in the instructions below.
When you initially came to the hospital, your creatinine was a
little elevated. Creatinine is a quantity that we can measure in
the blood that helps us estimate your kidney function. Your
creatinine value normalized during your hospitalization and
continued to remain normal throughout your hospital stay.
INSTRUCTIONS:
STOP the lisinopril that you took at home before you came to the
hospital. Your doctor may want to restart this as an outpatient.
START taking metoprolol 50mg three times per day.
START taking digoxin 125mcg every day.
START taking coumadin 5mg every day.
Please go the the following appointments listed below, including
this Thursday in the post discharge clinic and Monday with Dr.
[**First Name (STitle) **].
A nurse will come to your house for the next few days to make
sure that the oxygen levels in your blood are appropriate.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2152-4-13**] 9:00 AM
Phone: ([**Telephone/Fax (1) 1921**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2152-4-17**] at 4:10 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2152-5-15**]
11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2152-5-31**]
9:20
Completed by:[**2152-4-11**]
ICD9 Codes: 486, 5849, 2761, 5119, 4271, 4240, 4019, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4727
} | Medical Text: Admission Date: [**2180-1-24**] Discharge Date: [**2180-1-27**]
Date of Birth: [**2103-7-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Coronary artery dissection
Major Surgical or Invasive Procedure:
cardiac catheterization with balloon angioplasty
History of Present Illness:
This is a 76 year old man has a history of hypertension,
hyperlipidemia, atrial fibrillation and known CAD s/p remote RCA
angioplasty in the mid [**2158**]'s at [**Hospital6 2752**]. The
patient reports that he has recently noticed an increase in
exertional chest discomfort and shortness of breath. He remarks
that his DOE was the most pronounced, only able to walk a few
[**Age over 90 **] yards before becoming SOB. He also has had CP with exertion,
but this has not escalated recently. For this reason, he
underwent cardiolite stress testing on [**2179-12-29**]. He exercised 4
minutes 30 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, reaching 88% of max PHR.
He had no anginal symptoms. EKG was notable for 2mm ST
depression in leads V1-V5, likely secondary to repolarization
changes. Imaging revealed inferior and posterolateral ischemia.
LVEF was 44% at rest, 58% with stress.
Pt also reports occasional lightheadedness and presyncopal
symptoms, but not related to exertion, over the past year. He
denies syncope, orthopnea, PND. He also notices occasional
palpitations.
.
He underwent cardiac catheterization today which was complicated
by circumflex dissection. Developed CP but no ECG changes with
cath. [**Month (only) **] flow into major OM, on heparin and integrillin.
Transient hypotension, no tamponade or perf. Got 5 min dopa and
atropine as this was likely vagal. Foley catheter placed as
unable to pee. Pt was having 1/10 chest pain, flow thru LCx.
Wedge [**10-4**] at end of case. IVF started in lab.
.
On transfer to the CCU, he continues to have 2/10 chest pain,
otherwise has no complaints. His pain is relieved after
morphine.
.
On review of systems, positive for occasional constipation, and
has had leg cramping with walking for several years.
Otherwise denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p RCA angioplasty
in the mid [**2158**]'s
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Possible prior silent MI per patient report
CAD s/p RCA angioplasty in the mid [**2158**]'s at [**Hospital3 **]
Moderate to severe aortic stenosis by echocardiogram [**2179-5-25**]
Atrial fibrillation
Carotid artery disease (less than 50% stenoses bilaterally)
Retinal emboli 5-6 years ago with partial loss of vision of
right eye
Left arm bone grafts following an MVA
Arthritis
Hypothyroidism
Mild anemia
PVD [**10-1**] revealing a right ABI of 0.77 left 0.67.
Asbestosis with pleural plaques and calcifications
GERD found on EGD
Sleep apnea (could not tolerate CPAP)
Chondrocalcinosis
Osteochondritis
Colonic polyp
Social History:
Patient is widowed with five children. His oldest son
intermittently lives with him. He previously was employed as a
carpenter, building houses.
Tobacco: Quit 18 years ago, previously smoked socially on
weekends for 30-40 years
ETOH: Occasional one beer or glass of wine 5-6x/wk
Family History:
Brother with [**Name2 (NI) 499**] cancer. Brother also with CAD, though unknown
if MI
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died of CA (type unknown)
- Father: [**Name (NI) **] disease - possibly asbestosis
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.5 BP=144/81 HR=60 RR=17 O2 sat=98% 2LNC
GENERAL: Pleasant male, lying down in bed, NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP non-elevated....
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. IV/VI harsh systolic ejection murmur
at RUSB with radiation to carotids, slightly late peaking, but
S2 heard, +parvus et tardus, No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly without
crackles or wheezes
ABDOMEN: +BS, several ecchymoses on abdomen, Soft, NTND. No HSM
or tenderness. Abd aorta not enlarged by palpation. No abdominal
bruits.
EXTREMITIES: warm, slightly cooler on lateral aspects of feet,
No femoral bruits, gauze in place on right groin
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP unable to palpate PT 2+ dopplered
bilaterally
Left: Carotid 2+ Radial 2+ DP 1+ PT 2+ dopplered bilaterally
.
DISCHARGE PHYSICAL EXAM:
Afebrile, VSS
Gen: NAD, lying in bed
HEENT: supple, JVD at 7 cm
CV: RRR, 2/6 systolic murmur at Left upper sternal border, no
radiation. Left pectoral area with mild bruising, no hematoma or
lumg, tenderness with palpation
RESP: crackles left base, no wheezes
ABD: soft, NT, ND
EXTR: pulses faintly palpable, no arterial changes, feet warm.
No edema.
Extremeties: Right groin site with mild ecchymosis, no bruit, no
hematoma.
Pulses:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Skin: intact
Pertinent Results:
ADMISSION LABS:
[**2180-1-24**] 01:00PM BLOOD WBC-4.5 RBC-3.66* Hgb-11.8* Hct-33.3*
MCV-91 MCH-32.2* MCHC-35.4* RDW-13.0 Plt Ct-197
[**2180-1-24**] 08:05AM BLOOD PT-13.1 INR(PT)-1.1
[**2180-1-24**] 05:40PM BLOOD Glucose-110* UreaN-14 Creat-0.9 Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2180-1-24**] 05:40PM BLOOD ALT-136* AST-91* LD(LDH)-207 CK(CPK)-224
AlkPhos-55 TotBili-0.6
[**2180-1-24**] 05:40PM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
.
CARDIAC ENZYMES:
[**2180-1-24**] 05:40PM BLOOD CK-MB-21* MB Indx-9.4* cTropnT-0.12*
[**2180-1-25**] 01:45AM BLOOD CK-MB-84* MB Indx-12.2*
[**2180-1-25**] 07:38AM BLOOD CK-MB-71* MB Indx-11.1* cTropnT-1.07*
[**2180-1-25**] 01:08PM BLOOD CK-MB-50* MB Indx-9.7* cTropnT-0.84*
[**2180-1-26**] 06:40AM BLOOD CK-MB-16* MB Indx-6.5* cTropnT-0.70*
.
PERTINENT LABS:
[**2180-1-24**] 05:40PM BLOOD %HbA1c-5.7 eAG-117
[**2180-1-25**] 07:38AM BLOOD Triglyc-81 HDL-38 CHOL/HD-3.2 LDLcalc-69
[**2180-1-25**] 07:38AM BLOOD Digoxin-0.5*
.
DISCHARGE LABS:
[**2180-1-27**] 06:50AM BLOOD WBC-4.4 RBC-3.35* Hgb-11.1* Hct-31.0*
MCV-93 MCH-33.2* MCHC-35.9* RDW-13.3 Plt Ct-158
[**2180-1-27**] 06:50AM BLOOD Glucose-93 UreaN-18 Creat-1.1 Na-138
K-4.1 Cl-104 HCO3-26 AnGap-12
[**2180-1-27**] 06:50AM BLOOD ALT-91* AST-59* AlkPhos-50
[**2180-1-27**] 06:50AM BLOOD Mg-2.0
.
STUDIES:
CARDIAC CATH [**2180-1-24**]: PRELIM READ:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD had a tubular 60% proximal stenosis. The LCx had an 80%
proximal
stenosis. The RCA had moderate diffuse disease without
angiographically
significant stenoses.
2. Resting hemodynamics revealed a normal pulmonary capillary
wedge
pressure of 8mmHg. The pulmonary arterial pressure was normal
with PASP
27mmHg. The cardiac index was preserved at 2.5 L/min/m2. The
systemic
vascular resistance was slightly elevated at 1382 dynes-sec/cm5
and the
pulmonary vascular resistance was normal 87 dynes-sec/cn5. There
was
mild systemic arterial hypertension with SBP 147 mmHg and DBP 98
mmHg.
3. Pressure wire of the proximal LAD stenosis revealed a
baseline FFR of
0.95, which fell to 0.82 at maximal hyperemia.
4. Unsuccessful attempt at PTCA and stenting of LCx lesion
complicated
by spiral dissection and unsuccessful attempt to re-cross into
true
lumen.
5. Transient hypotension likely due to vagal episode, resolved
with
atropine and brief dopamine. Bedside echo did not show any
effusion.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease of the LAD and LCx.
2. Unsuccessful PCI of LCx complicated by dissection and closure
of
Lcx/OMB with filling of distal OMB by left to left collaterals.
3. If recurrent chest pain or hemodynamic instability, consider
CABG.
4. Successful pressure wire of LAD.
5. Admit to CCU.
.
TTE [**2180-1-24**]:
Conclusions
The left ventricular cavity size is normal. Right ventricular
chamber size and free wall motion are normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: No significant pericardial effusion identified.
.
TTE [**2180-1-25**]:
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild basal inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
50-55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
There is mild to moderate aortic valve stenosis (valve area 1.2
cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: No significant pericardial effusion. Mild regional
left ventricular systolic dysfunction, c/w CAD. Mild to moderate
calcific aortic stenosis. Mild pulmonary hypertension.
.
MICRO:
URINE CX [**2180-1-24**]:
[**2180-1-24**] 5:09 pm URINE Source: Catheter.
**FINAL REPORT [**2180-1-26**]**
URINE CULTURE (Final [**2180-1-26**]):
BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML..
Brief Hospital Course:
HOSPITAL COURSE:
This is a 76 year old man has a history of hypertension,
hyperlipidemia, atrial fibrillation and known CAD status post
remote RCA, who presented for cath today, and had dissection to
LCx.
.
ACTIVE ISSUES:
# CAD: Pt with known CAD, s/p RCA angioplasty in [**2158**]'s, now
status post catherization with dissection to LCx. Patient
initially had pain post-procedure, relieved by morphine. Repeat
EKG on the floors were largely unchanged, without evidence of
active ischemia in LCx region. TTE without evidence of
pericardial effusion. Cardiac enzymes were cycled and peaked at
a CK of 84 on [**1-25**], and subsequently downtrended. He was started
on heparin gtt and integrillin at 2mcg/kg/min overnight. He was
continued on ASA 325mg daily, and Plavix was held given no
indication for therapy and consideration for CABG. Lisinopril
was also held given large dye load with cath. He was continued
on Atorvastatin 40mg daily. He was started on metoprolol
succinate for beta blockade. He was also started on Imdur ER 30.
Csurg was consulted, and recommended no need for surgery at this
time. He will follow-up with cardiology. Plavix was not
restarted on discharge given no indication for continued
therapy.
.
# PUMP: Recent stress demonstrated EF 44%, improved to 58% with
exertion. Appeared euvolemic on presentation. Strict I&O's,
daily weights, without evidence of fluid overload. TTE on [**2180-1-25**]
demonstrated mild regional left ventricular systolic dysfunction
with EF of 50-55%.
.
# RHYTHM: Paroxysmal afib, on coumadin and digoxin at home;
coumadin had been held, Lovenox started prior to cath. Sinus
bradycardia on the floors. Heparin gtt was continued for
anticoagulation, given possibly going for surgery with csurg. He
was continued on amiodarone 200mg daily, and Digoxin was
discontinued. He was discharged on daily coumadin with lab
request for follow-up INR. INR at time of discharge was 1.1.
.
# Large dye load: Pt received 500cc contrast with cath. He was
given IVF, and creatinine on discharge was 1.1.
.
# HTN: Pt was briefly hypertensive post-procedure, and placed
on nitro gtt, which was weaned prior to transfer. As above, ACEI
was held given dye load and concern for acute renal failure.
Nitro gtt was discontinued given moderate to severe AS and
concern for preload dependancy. He was discharged on isosorbide
and metoprolol succinate for blood pressure control. Lisinopril
was held. He was instructed to follow-up with Dr. [**Last Name (STitle) 7047**] for
discussion of when to restart ACEI.
.
# Transaminitis: Likely [**1-26**] cardiac ischemic; LFT's were
monitored and downtrended.
.
# Anemia: Hct 35 on admission, compared to Hct 39 per data at
OSH. Pt had no s/s bleeding. Hct remained stable.
.
INACTIVE ISSUES:
# HLD: Continued on Atorvastatin 40mg daily.
.
# Hypothyroidism: Continued on home dose Levothyroxine 150mcg
daily.
.
.
TRANSITIONAL CARE:
# CODE: FULL, CONFIRMED WITH PATIENT
# FOLLOW-UP: Dr. [**Last Name (STitle) 7047**] and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
# OUTSTANDING LABS: None
.
# Follow-up: Day after discharge, urine culture resulted with
beta group strep B infection. Pt was contact[**Name (NI) **] and instructed to
take 10 day course of ampicillin and instructed to have repeat
UA after treatment to ensure eradication of infection.
Medications on Admission:
AMIODARONE 200 mg Tablet qday
ATORVASTATIN 40 mg 1 tab qhs
DIGOXIN 125 mcg Tablet qday
ENOXAPARIN [LOVENOX] 150 mg/mL Syringe - once a day beginning
[**2180-1-20**] pre catheterization
LEVOTHYROXINE 150 mcg Tablet qam
LISINOPRIL 10 mg Tablet qam
WARFARIN 2 mg as directed(recently 2 tablets, total 4), last
[**1-18**] pre-cath
ASPIRIN 81 mg Tablet daily
GLUCOSAMINE-CHONDROIT-VIT
MULTIVITAMIN
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg Capsule daily
Plavix - last dose: No plavix today
Cialis 10mg po prn - last used 2 weeks ago
Garlic tabs occasionally
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take up to 3 tablets 5 minutes apart. Call Dr. [**Last Name (STitle) 7047**] for any
pain.
Disp:*25 Tablet* Refills:*0*
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Glucosamine Complex Oral
9. Outpatient Lab Work
Please check INR, chem-7 on Monday [**2180-2-1**] and call results to
Dr. [**Last Name (STitle) 7047**] at [**Telephone/Fax (1) 8725**]
10. metoprolol succinate 25 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*
11. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Acute Coronary syndrome related to dissection
Hypertension
Atrial Fibrillation
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a complicated cardiac catheterization and needed a large
amount of contrast during the procedure. We found 3 coronary
vessels that were partially blocked. Two of these vessels still
had adequate blood flow and were not treated. The left sided
artery was blocked and was opened with a balloon and a small
dissection was also treated using a balloon. You had some heart
muscle damage during the procedure but your heart function is
still strong and you have recovered well.
.
We made the following changes to your medicines:
1. Increase aspirin to 325 mg daily
2. Stop Digoxin
3. Start Metoprolol to lower your heart rate
4. Continue your warfarin at your previous dose, check INR on
Monday [**2-1**].
5. Take nitroglycerin as needed for chest pain
6. Start taking Imdur to help keep your arteries open and
prevent chest pain.
Followup Instructions:
Name: RING,[**Doctor First Name 569**] L.
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 28095**]
*Please call Dr. [**Last Name (STitle) **] to book an appointment within one week.
Name: [**Last Name (LF) 7047**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/Cardiology
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
*Someone from Dr. [**Last Name (STitle) 35067**] office will call you to book an
appointment. If you dont hear back in 2 days, please call the
number above.
Completed by:[**2180-1-29**]
ICD9 Codes: 4019, 2724, 412, 4241, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4728
} | Medical Text: Unit No: [**Numeric Identifier 65095**]
Admission Date: [**2144-12-11**]
Discharge Date: [**2144-12-22**]
Date of Birth: [**2144-12-11**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 65096**] [**Known lastname **] is the
2.925 kilogram product of a 36 and [**12-5**] week gestation born to
a 31-year-old G2 P0 mom. Prenatal screens B positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
negative, GBS unknown, no fever at delivery and no prolonged
rupture of membranes. Mother was insulin dependent diabetic
since age 7 and was on an insulin pump during pregnancy. Her
hemoglobin A1C was 5.7. She has a history of chronic
hypertension, retinopathy and nephropathy. Mother was treated
with Dilantin, Aldomet, Synthroid in addition to her insulin.
Infant was born by C section secondary to maternal chronic
illness. Infant received Apgars of 8 and 9 at 1 and 5 minute
respectively. In the delivery room, she was given some blow
by O2, dried and bulb suctioned. Initially she was sent to
the newborn nursery where she was noted to have a D stick of
38, was fed with a repeat D stick of 58. She had several more
D sticks that were hypoglycemic and was transferred to the
NICU for further management.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2.925 grams, 75th
percentile, head circumference 33 cm 75th percentile, length
46 cm 50th percentile. Normocephalic atraumatic anterior
fontanelle open and flat. [**Last Name (un) 20696**] intact. Red reflex deferred.
Neck supple. Lungs clear bilaterally. Cardiovascular regular
rate and rhythm. No murmur. Femoral pulses 2+ bilaterally.
Abdomen soft with bowel sounds. No masses or distention.
Extremities warm and well perfused. Brisk cap refill. GU
normal female. Hips stable. Clavicles intact. Thigh midline.
No sacral dimple. Neuro, good tone. Normal suck and gag.
HOSPITAL COURSE: Respiratory, [**Known lastname 41356**] was in room air
throughout her hospital course. She did have several episodes of
apnea bradycardia on day of life 3. She has been 5 days apnea
and bradycardia free as of [**12-22**].
Cardiovascular, no issues.
Fluid and electrolytes. Her initial D sticks were
hypoglycemia, with a low of 32. Required D10 at 40 per kilo
and ad lib enteral feedings. She has been off IV fluids since
day of life #2 and has been stable with ad lib feedings since
that time.
GI, peak bilirubin was 9.7/0.2 on day of life #6. She has not
required any interventions.
Hematology, hematocrit on admission was 40.3.
Infectious disease, CBC and blood culture were obtained on
admission and a repeat CBC and blood culture obtained on day
of life 3 in light of respiratory apnea and bradycardia. Both
CBCs and blood cultures were negative and infant has not
received any antibiotics.
Neuro, she has been appropriate for gestational age.
Hearing screen was performed with automated auditory
brain stem responses and the infant passed prior to discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 40499**]. The
family is going to follow up with Dr. [**Last Name (STitle) 42184**] [**Telephone/Fax (1) 42185**].
MEDICATIONS: Tri-Vi-[**Male First Name (un) **] 1 ml po every day.
CAR SEAT POSITION SCREENING: Car seat test was passed prior to
discharge.
STATE NEWBORN SCREEN: State newborn screen has been sent per
protocol on [**2144-12-14**] and [**2144-12-22**].
IMMUNIZATIONS: Infant received hepatitis B vaccine on
[**2144-12-13**].
Immunizations recommended, Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] with infants who meet any
of the following 3 criteria;
1)born at less than 32 weeks, born between 32 and 35 weeks with
2 of the following, day care during RSV season a smoker in
the household, neuromuscular disease, airway abnormalities or
school age siblings or with chronic lung disease.
Influenza immunizations 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.
DISCHARGE DIAGNOSES: Infant of a diabetic mother,
hypoglycemia, apnea and bradycardia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2144-12-22**] 07:47:29
T: [**2144-12-22**] 08:17:58
Job#: [**Job Number 48769**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4729
} | Medical Text: Admission Date: [**2196-3-4**] Discharge Date: [**2196-3-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Shortness of breath and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a history of severe
COPD on home oxygen, diastolic heart failure, and kyphoscoliosis
who presents from rehab with hypoxia and shortness of breath.
She was discharged from this hospital on [**2195-12-30**] at which time
she was requiring 60% face mask high flow O2 to maintain oxygen
saturations of 88-90%. She was initially discharged to [**Hospital1 **]
where she showed rapid improvement with antibiotics and after
one month was discharged to [**Hospital1 2436**] and finally to Admiral
[**Doctor Last Name **] nursing home on [**2196-2-24**]. At that time she was requiring
between 3-4 liters nasal canula to maintain saturations in the
high 80s to low 90s at rest. The events of today are unclear.
She reports that she was trying to get to the dining [**Doctor Last Name **] and
had to walk around the facility. This was significantly more
exercise than she typically gets. She sat down and felt short
of breath. She was wearing her oxygen at the time. Her oxygen
saturations were noted to be in the 70s on 5L nasal canula. She
was not experiencing any fevers, chills, cough, congestion,
lightheadedness, dizziness or chest pain. She was experiencing
significant nasal congestion. She received a nebulizer therapy
by EMS and by the time of arrival at [**Hospital1 18**] here oxygen
saturation was 96%.
.
In the ED, initial vs were: T: 97.7 BP: 120/50 P: 60 R: 20 O2
sat: 96% on nebulizer. She had a CXR which showed bilateral
pleural effusions and possible bilateral pneumonia although not
significantly changed from her previous films. She received
ceftriaxone, azithromycin and levofloxacin. She also received
nebulizers and solumedrol. She had an EKG which showed atrial
fibrillation but no acute ST segment changes. She was satting
in the mid 90s on 50% facemask. She was admitted to the ICU for
further managemen.
.
Upon arrival to the ICU she reports that she feels well. She is
hungry. She denies fevers, chills, chest pain, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. She endorses nasal congestion but no cough
or sore throat. She does not completely recall the events of
today. All other review of systems negative in detail.
Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)
Social History:
Lives at nursing home. Ambulates with a walker at baseline.
Alert and oriented x 3 at baseline. On home oxygen 3-4L. Past
smoker but quit 30 years ago. No ethanol or illict drugs. Son
and daughter live nearby and are involved.
Family History:
Positive for hypertension and type II diabets. Given age
non-contributory to current illness.
Physical Exam:
Physical Examination
Vitals: T: 97.1 BP: 123/63 P: 74 R: 18 O2: 96% on 10L
aerosolized mask
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, nasal passages
with erythema and congestion
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at bases, dull to percussion at
bases, expiratory wheezes heard throughout lung fields
CV: irregular, s1 + s2, 2/6 SEM at RUSB, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema bilaterally
Brief Hospital Course:
Assessment and Plan: Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a
history of severe COPD on home oxygen, diastolic heart failure,
and kyphoscoliosis who presents from rehab with hypoxia and
shortness of breath.
Shortness of Breath/Hypoxia: While in the ICU patient appeared
not particularly far from baseline. It was suspected that her
relative respiratory decompensation was due to a large component
of COPD exacerbation possibly from viral upper respiratory tract
infection. Condition exacerbated by known bilateral effusions,
chronic RLL collapse and restrictive lung disease from
kyphoscoliosis. Her CXR was difficult to interpret but was not
significantly changed from prior films. She had no fevers,
chills, or leukocytosis. She does not have increased sputum
production. She has no signs and symptoms of cardiac ischemia.
She did not appear significantly volume overloaded on exam.
Patient given dose of levofloxacin and then antibiotics were
discontinued as bacterial infection was not believed to be
driving force behind symptoms. She was initiated on prednisone
60mg qd with standing alb/ipratropium nebs. A BNP was done
which was 1655 which was acually below her baseline. She was
quickly able to be called out to the floor. Her respiratory
symptoms gradually improved and she was tapered to 40mg
prednisone on day of discharge with plan to continue slow taper
on discharge. She was continued on her home dose of lasix. Her
home acetazolamide was discontinued due to concerns about
increasing C02 production in a pt with already low reserve from
COPD. Her 02 sats were in high 80s to mid 90s, even during walks
with PT and she was stable on her home dose of 3.5L NC 02.
Diastolic Heart Failure: Most recent echocardiogram in [**2194**]
actually with hyperdynamic left ventricle and normal LV wall
thickeness. She was continued on her home dose of lasix,
acetazolamide discontinued as above.
Atrial Fibrillation: Chronic, on coumadin and beta blockers at
home. Her INR was supratherapeutic while hospitalized, her
coumadin was held until day of discharge, at which time it was
restarted at home doses for INR of 2.0. Her heart rate was
increased in AF necessitating increase in her beta blockade with
good effect, stable BP.
Anxiety: Stable.
- continued celexa
- continued buspar
- continued PRN ativan
Anemia: Chronic, normocytic to macrocytic. At baseline.
- monitored hematocrit, was stable. Iron deficient by labs,
discharged on iron.
- B12, folate WNL
Seen by speech language pathology due to concerns about coughing
with meals, was placed on a soft dysphagia diet with thin
liquids.
After PT eval and recommendation, pt discharged with stable
vital signs and baseline oxygenation to short term rehab.
Communication: [**Name (NI) **] (son/power of attorney)
[**Telephone/Fax (5) 81861**]. [**Doctor First Name **] (daughter)
[**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**].
Medications on Admission:
Milk of Magnesia
Dulcolax
Fleets
Tylenol PRN
Acetazolamide 250 mg [**Hospital1 **]
Albuterol nebulizer TID
Ascorbic Acid 500 mg [**Hospital1 **]
BuSpar 10 mg daily
Celexa 40 mg daily
Lasix 120 mg [**Hospital1 **]
Ipratropium nebulizers TID
Lidocaine patch 1 patch daily
Toprol XL 50 mg daily
Multivitamin daily
Omeprazole 20 mg daily
Micro-K 20 mg daily
Senna
Coumadin 2.5 alternating with 3 mg daily
Colace
Lorazepam 0.25 mg PRN
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for shortness of breath or wheezing.
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Buspirone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours).
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP <90.
15. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO 3X/WEEK (TU,TH,SA).
16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR): Adjust dose as needed for goal INR [**12-29**].
17. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): STEROID TAPER:
Take 2 tablets daily for 5 days; then 1 tablet daily for 5 days;
then [**11-27**] tablet daily for 5 days, then stop. .
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Ferrous Gluconate 225 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day: Do not take with maalox.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2436**] Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
COPD exacerbation
Iron deficiency anemia
Dysphagia
Secondary Diagnoses:
Diastolic Congestive Heart Failure
Depression
Discharge Condition:
Stable vital signs, maintaining baseline oxygenation of 88-93%
on 3.5L while ambulating, tolerating an oral diet.
Discharge Instructions:
You were admitted with difficulty breathing and low oxygen
levels. You were not found to have any evidence of infection.
You were treated for an exacerbation of your COPD with steroids
and nebulizers. You will need to complete a slow taper of these
steroids. You were found to have an iron deficiency anemia, you
should take iron pills for this, will stool softeners if need be
as this can cause constipation.
Your metoprolol for your atrial fibrillation was increased to
control your heart rate.
Your coumadin was held briefly for elevated levels and restarted
prior to discharge. You should continue to get regular blood
draws to check on these levels and adjust dosing as needed.
Please take all medications as prescribed. Please follow up with
your primary care physician [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] after discharge.
Call your doctor or return to the emergency room if you
experience worsening shortness of breath not responsive to
nebulizer treatment, fevers, chills, dizziness or loss of
consciousness or for any other concerning symptoms.
Followup Instructions:
Call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 608**] for a follow up
appointment within 1-2 weeks of discharge.
ICD9 Codes: 5180, 5119, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4730
} | Medical Text: Admission Date: [**2141-8-5**] Discharge Date: [**2141-8-6**]
Date of Birth: [**2081-6-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
s/p arrest
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
60 M with pmhx of HTN, Hyperlipidemia, Diabetes, ? HF, had a
witnessed cardiac arrest getting into a car after applying for a
fishing license. He was witnessed to collapse and CPR was
initiated by a bystander, continued for about 10 minutes. EMS
arrived found him in asystole and epix5 /atropinex2 were
administered, he went into a wide complex rhythm, administered
amiodarone 50mg bolus at 1626 then 0.5mg/hr , rhythm progressed
to afib/then sinus tachycardia, in addition he was on a dopamine
IV infusion at 10mg weaned to 5mg. He was given 40mg of lasix
and started on a heparin drip.
Initial VS in ED was 98 101 99/24 13 97, bagged, WBC
17/11.1/33.9/197, K 5.6, glucose 311, intubated AC 700x12 100%
abg 7.03/80/100/21 CXR with CHF pulmonary edema. CK 128 MB 6
Trop I 0.04. PT 13.6 PTT 26.2, INR 1.2 Tox screen negative.
His EKG had ST depression in the anterior/lateral leads. His
initial labs was with hyperkalemia at 5.6 and he was given
insulin/D50. He was intubated for airway protection and his
first ABG was 7.03/80/100/21, a repeat was 7.25/52/89.
On arrival to CCU, he is unresponsive to vigorous sternal rub,
only response that can be elicited is a startle response to
forehead tapping, no posturing, [**Location (un) 2611**] 3.
.
On Hx from daughter, patient requires home o2 at night, does not
ambulate, uses wheelchair, baseline can only ambulate a few
feet. Recent hospitalizations to [**Hospital1 **] in [**Month (only) **]/06, and B/W [**2-4**]
years ago.
Past Medical History:
IDDM
HTN
Hyperlipidemia
Morbid Obesity
Heart Failure
Alcoholism DTs in past
R prox humerus Fx s/p ORIF
ARthritis
Verntral Hernia
Macular Degeneration
CHF EF 40-45%
Social History:
100 packyear smoking,
Family History:
paternal uncle died of MI in 60s
Physical Exam:
VS: T 100.2 , BP 90/60, HR 92, RR on vent, O2 96 % on AC rate
12/700, FiO 100, PEEP 5.
Gen: unresponsive to vigorous sternal rub, intubated.
HEENT: NCAT. Sclera anicteric. Pupils fixed at 3 mm.
Neck: JVD cannot be assessed due to body habitus.
CV: PMI located in 5th intercostal space, midclavicular line.
Irregularly irregular rhythm, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
Intubated. Diffuse crackles greatest in Right base,
Abd: Obese, soft, two large partially reducible hernias. No
abdominal bruits.
Ext: Non pitting edema bilaterally. Chronic skin changes
consistent with PVD.
Skin: Stasis dermatitis in lower extremities.
Pulses: only doppler in LLE, warm to touch throughout
MENTAL STATUS: unresponse to verbal or tactile stimuli
CRANIAL NERVES:
II: pupils fixed at 2mm bilaterally, w/o response
III, IV, VI: fixed in midline position, eye do not deviate w/
occulo-cephalic refex, no blink
V: unable to access.
VII: no facial droop.
VIII: unable to access.
IX, X, [**Doctor First Name 81**]: no gag
XII: unable to access.
MOTOR SYSTEM: does not withdraw to pain in any extremity, flacid
REFLEXES:
B T Br Pa Pl
Right 0---------->
Left 0---------->
Grasp reflex absent; snout, glabellar, palmomental absent.
Toes: mute bilaterally.
SENSORY SYSTEM: unable to access
COORDINATION: unable to access
GAIT: unable to access
Pertinent Results:
EEG: diffuse slowing with no variability
.
EKG demonstrated EKG Wide complex tachycardia 120bpm, peaked T
waves, ST depression V4 V5.
CXR demonstrates widened mediastinum, cardiomegaly, pulmonary
edema.
.
TELEMETRY demonstrated: A Fib, rate 90s.
.
HEMODYNAMICS:
.
LABORATORY DATA:
Studies:
[**2141-8-5**]
Head CT- Prelim no bleed, hernation, masses
Chest CT- No PE, pulmonary edema, possible b/l aspiration PNA,
ABD CT- Transverse colon entering hernia, small
ileus/obstruction level of the ileum, dilated cecum,
hypodensities in the liver, cysts in the kidney (1 complex).
[**2141-8-5**] 06:40PM GLUCOSE-266* UREA N-63* CREAT-1.8* SODIUM-138
POTASSIUM-6.4* CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2141-8-5**] 06:40PM estGFR-Using this
[**2141-8-5**] 06:40PM ALT(SGPT)-71* AST(SGOT)-90* CK(CPK)-401* ALK
PHOS-138* TOT BILI-0.2
[**2141-8-5**] 06:40PM CK-MB-20* MB INDX-5.0 cTropnT-0.19*
[**2141-8-5**] 06:40PM CALCIUM-7.8* PHOSPHATE-6.0* MAGNESIUM-2.2
CHOLEST-104
[**2141-8-5**] 06:40PM TRIGLYCER-53 HDL CHOL-49 CHOL/HDL-2.1
LDL(CALC)-44
[**2141-8-5**] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-8-5**] 06:40PM WBC-13.9* RBC-4.22* HGB-12.1* HCT-38.5*
MCV-91 MCH-28.7 MCHC-31.5 RDW-14.9
[**2141-8-5**] 06:40PM NEUTS-89.9* LYMPHS-6.8* MONOS-2.6 EOS-0.3
BASOS-0.3
[**2141-8-5**] 06:40PM PLT COUNT-277
[**2141-8-5**] 06:40PM PT-12.0 PTT-27.6 INR(PT)-1.0
Brief Hospital Course:
60 YO M with extensive past medical history presenting s/p
witnessed pulseless arrest with questionable bystandard CPR.
His cardiac enzymes were positive and it is possible that his
arrest was secondary to myocardial infarction; or equally
possible that he had a primary arrhthmic event. Upon arrival to
the CCU he had signs of very severe neurologic injury with GSC
of [**3-5**] off of sedation with absolutely no response to pain, no
gag reflex, abnormal doll's eyes, no corneal reflex. His only
sign of brainstem function were sluggish pupil response. He was
intubated for airway protection; neurology was consulted. He
was also acidotic/hyperkalemic which was treated with dextrose,
insulin, bicarbonate, and kayexalate to good effect. He was
mechanically ventilated on assist control mode. At the
suggestion of Neurology his sedation was weaned to off and his
neurologic status was re-evaluated with no clinical change. He
demonstrated significant autonomic with periods of severe
hypertension/tachycardia with alternating hypotension. He also
had [**Location (un) **] respirations with hyperventilation leading to a
primary respiratory alkalosis. At this point his family
expressed his (and their wishes) to ony pursue aggressive
measures if he was sure to have a good neurologic outcome.
Because of his very poor neurologic prognosis the family met
with the primary team and the neurology attending, discussed the
case in detail and all aggreed that they wanted to withdraw
care. He was extubated at 6:55pm on [**2141-8-6**] and he died of
respiratory failure a few minutes later. The family denied
autopsy.
Medications on Admission:
Allopurinol 300mg daily
Bumatanide 2mg daily
Humalog 75/25 40qam
Lisinopril 5 mg daily
Metoprolol 50mg daily
Plavix 75 mg daily
Simvastatin 40mg qhs
Zantac 150mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
myocardial infarction
V-tach cardiac arrest
anoxic brain injury
acidosis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 4271, 4280, 2767, 2762, 5070, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4731
} | Medical Text: Admission Date: [**2165-4-24**] Discharge Date: [**2165-4-27**]
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
ORIF of Lt ulna and radius
History of Present Illness:
[**Age over 90 **] yo F transferred from ortho clinic today due fracture of
distal radius and ulna requiring surgery. Patient fell 3 days
ago when cat knocked her down. The exact details of the fall
are
unclear. [**Name2 (NI) **] did not seem well the next day so she was
taken
to HV Urgent Care where fracture of wrist was found. At that
time she was referred to ortho clinic. Today at clinic her
xrays
were reviewed by Dr. [**Last Name (STitle) 1024**] and she was sent to the ED for
surgery/admission.
Past Medical History:
PMHx:
Idiopathic liver cirrhosis
Cataracts
Hyponatremia
PSx:
Cataract surgery
Social History:
Lives at home alone
Has cats at home
Non-smoker
No alcohol use
Family History:
NC
Physical Exam:
AFVSS
NAD
RRR
CTAB
S/NT/ND
LUE: Sensation intact to light touch. Fingers motor intact.
Pertinent Results:
[**2165-4-24**] 05:40PM BLOOD WBC-6.0 RBC-2.98* Hgb-10.9* Hct-31.5*
MCV-106* MCH-36.5* MCHC-34.5 RDW-13.8 Plt Ct-127*
[**2165-4-27**] 01:29AM BLOOD Hct-32.9*
[**2165-4-24**] 05:40PM BLOOD Glucose-126* UreaN-36* Creat-1.5* Na-141
K-4.4 Cl-104 HCO3-25 AnGap-16
[**2165-4-27**] 05:40AM BLOOD Glucose-114* UreaN-37* Creat-1.2* Na-139
K-3.5 Cl-104 HCO3-24 AnGap-15
[**2165-4-24**] 05:40PM BLOOD ALT-38 AST-60* AlkPhos-75 TotBili-1.4
[**2165-4-27**] 05:40AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.7
Brief Hospital Course:
Mrs.[**Known lastname 89432**] presented to the [**Hospital1 18**] on [**2165-4-24**] after a fall. She
was evaluated by the orthopaedic surgery service and found to
have a left forearm radius and ulna fracture. She was admitted,
consented, and prepped for surgery. On [**2165-4-25**] she was taken to
the operating room and underwent an ORIF of her left radius and
ulna. She tolerated the procedure well, was
extubated,transferred to the recovery room, and then to the
floor. On POD 2, she recieved 2 units of PRBCs for postoperative
blood loss. Her Hct was stable thereafter.
She will be discharged to rehab and follow up with us in 2
weeks.
Otherwise, the rest of her hospital stay was uneventful with his
lab data and vital signs within normal limits and her pain
controlled. She is being discharged today in stable condition.
Medications on Admission:
Lasix 20mg PO QD
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
left distal radius fracture
left ulna fracture
Discharge Condition:
AAO X 3
Regular diet
Discharge Instructions:
ACTIVITY:
Left lower extremity: touch down weight bearing
Right lowere xtremity: weight bearing as tolerated
Left upper extremity: weight bearing as tolerated
Right upper extremity: weight bearing as tolerated
General
If you have any increased pain, swelling, or numbness, not
relieved with rest, elevation, and or pain medication, or if you
have a temperature greater than 101.5, please call the office or
come to the emergency department.
Medications
1) Lovenox is a blood thinner that you should take for 4 weeks.
2)Pain medicine: You have been prescribed a narcotic pain
medication. Please take only as directed and do not drive or
operate any machinery while taking this medication. There is a
72 hour (Monday through Friday, 9am to 4pm) response time for
prescription refil requests. There will be no prescription
refils on Saturdays, Sundays, or holidays. Please plan
accordingly.
Wound Care:
- Keep Incision clean and dry.
- Do not soak the incision in a bath or pool.
- Staples should be removed in rehab on [**2165-5-7**]
Physical Therapy:
LUE: NWB
RUE: WBAT
LLE: WBAT
RLE: WBAT
Treatments Frequency:
Left upper extremity cast to stay on until follow up visit
Followup Instructions:
Please follow-up in [**Hospital 1957**] Clinic in 2 weeks please call [**Telephone/Fax (1) 26936**] for an appointment.
Completed by:[**2165-4-27**]
ICD9 Codes: 2875, 2761, 2851, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4732
} | Medical Text: Admission Date: [**2179-3-22**] Discharge Date: [**2179-3-22**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization - [**2179-3-22**]
History of Present Illness:
[**Age over 90 **] F with history of HTN, dCHF, severe AS, HLD who presented
initially to [**Location (un) 620**] from PCP office with complaint of chest
pressure anteriorly. She described it as substernal, constant
since last night. She felt exhausted and lightheaded and also
had some diarrhea last night. Also noticed some numbness in her
right leg whihc comes and goes. Was found to have EKG changes at
the PCP [**Name Initial (PRE) 3726**]. She had no prior cardiac history. Had been
seen last week at OSH ED and ruled out with -ve sets after
"strained muscle in her chest moving her arm". A CTA of the
chest showed mild emphysema, but no evidence of PE.
.
In [**Hospital1 **]-[**Location (un) 620**] ED, initial VS were 97.8, HR 109, BP 121/84, RR
22, 02 sat 78% and pain 0/10. In ED she was noted to have an o2
sat of 80% and was lightheaded. Found to be guaiac positive. She
got ASA and was started on a heaprin gtt (w/o bolus).
Transferred from [**Location (un) 620**] for STEMI. IN cath lab, they went in
through the lt radial huge and found a thrombus in lcx, mild
right disease. She got 600 plavix after cath, bival, bms in lcx,
and had a hematoma in lt radial. Transferred to CCU after
procedure.
Past Medical History:
HTN
HL
dCHF
Severe AS
GERD
Osteoprosis: Pseudoclaudication, likely because of spinal
stenosis, history of falls and shoulder injury, s/p ORIF right
patellar fracture [**2170**]
Social History:
resident of [**Location **] on the [**Doctor Last Name **], [**Location (un) **]. independant in
bathing, washing, feeding
- Tobacco history: ex-smoker in 60s
Family History:
non-contributory
Physical Exam:
On transfer to CCU
VS: 98.4, 103, 131/87, 19, 90% on NRB
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
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:
[**2179-3-22**] 05:22PM BLOOD CK(CPK)-1839*
[**2179-3-22**] 05:22PM BLOOD CK-MB-114* MB Indx-6.2* cTropnT-5.97*
Cardiac Cath ([**2179-3-22**])
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically
apparent disease. The LAD had a 30-40% mid vessel stenosis. The
Cx had a
100% mid vessel thrombotic occlusion. The RCA had a 30-40% mid
vessel
stenosis.
2. Limited resting hemodynamics revealed a central aortic
pressure of
132.86 mmHg.
3. Successful PTCA and stenting of the mid Cx with a 2.25x8mm
INTEGRITY
stent which was postdilated to 2.75mm. Final angiography
revealed no
residual stenosis, no angiographically apparent dissection and
TIMI II
to III flow (see PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PTCA and stenting of the mid Cx woth a BMS.
Bedside TTE ([**2179-3-22**])
Overall left ventricular systolic function is severely depressed
(LVEF= 15X %). with depressed free wall contractility. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. The mitral valve
leaflets are structurally normal. Moderate to severe (3+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
CXR ([**2179-3-22**])
Wide spread bilateral dense reticular opacities with relative
left lower lung and right mid lung sparing, likely representing
flash pulmonary edema due to acute cardiac decompensation in the
setting of ischemia/infarct.
Brief Hospital Course:
[**Age over 90 **] F with history of HTN, dCHF, severe AS, HLD who presented
from [**Hospital1 **] [**Location (un) 620**] with chest pain due to STEMI
.
#. STEMI/CAD - EKG at [**Location (un) 620**] concerning for STEMI, transferred
here for cardiac cath. Pt went straight to cath lab, was found
have an occluded LCX, and had a BMS deployed with good
restoration of flow. She had no previous history of coronary
artery disease and a recent echo did not show any evidence of
wall motion abnormality or significant valvular disease.
Arrived to CCU for further observation following procedure. She
shortly thereafter developed worsening oxygen requirement. Stat
CXR was performed which showed significant bilateral pulmonary
edema, likely flash pulmonary edema from acute cardiac
decompensation. Patient had initially said that she did not
want to be intubated, but wanted to have cardiac resuscitation.
Upon seeing CXR results, her son/HCP was immediately called to
discuss new findings and what this might represent. In light of
the fact that she had just undergone cardiac cath, the thought
that what was going on was likely [**2-4**] her STEMI and potentially
reversible if we pursued intubation and aggressive diuresis.
Code status was reversed from DNI to full code. As patient's
respiratory status worsened, she became more bradycardic and
more hypotensive. Anesthesia was called for elective
intubation, however patient quickly became hemodynamically
stable. Dopamine, then levophed were started peripherally as
patient did not have central access. Stat bedside TTE was
performed to evaluate valves as she just had STEMI. Mitral
valve was widely regurgitant, which is acutely changed from the
TTE she had at [**Location (un) 620**] a few weeks ago. Patient continued to
become more bradycardic, transcutaneous pacing was started.
Hemodynamics and respiratory status worsened. Code blue was
called. On holding transcutaneous pacing, patient was shown to
be in PEA arrest. Patient was coded with CPR, a total of 5
rounds of epinephrine, 3 rounds of atropine, 2 rounds of bicarb,
1 round of vasopressin. CCU and interventional attending was
called, decision was made not to bring patient back to the cath
lab. Pulse could not be recovered at any point during the code.
After 14 minutes, decision was made to stop code. Time of
death was 9:04 PM on [**2179-3-22**]. Family was present and updated
by the CCU team, they declined autopsy. Medical examiner waived
autopsy as well.
Medications on Admission:
- Dilt SR 180 qd
- Zetia 10 qd
- VitA-VitC-VitE-Min qd
- Ca-citrate 2g qd
- Brimonidine eye drops [**Hospital1 **]
- Latanoprost eye drops
- lasix 20 qd
- Diovan 160 qd
- Simvastatin 40
- Ranitidine 150 [**Hospital1 **]
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
STEMI
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
ICD9 Codes: 4019, 4280, 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4733
} | Medical Text: Admission Date: [**2163-9-20**] Discharge Date: [**2163-9-23**]
Date of Birth: [**2113-10-1**] Sex: M
Service: MEDICINE
Allergies:
Avandia
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 49 yo M with PMHx sig. for DM2 on only ISS, no
basal insulin who presents with hyperglycemia. He was sent to
[**Hospital **] clinic today by his PCP. [**Name10 (NameIs) 3754**] his FS was 498, HgbA1c was
14.5%.
He takes only an ISS, up to 6x per day. He has been on various
regimens in the past. His fingersticks are always 500-600. He
reports that if his BS is <275, he becomes lightheaded and
passes out. This has happened 3x in the past 2 months. He also
gets nauseous and vomits.
.
He has no localizing infectious complaints. Specifically, he
denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, palpitations, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. He has noted a 25 lb weight loss in the past year. He
has urinary frequency and drinks 5 gallons of water a day.
.
In the ED, initial VS: 97.4 103 128/85 18 100RA. Labs were sig.
for glucose of 525, anion gap of 17. Serum ketones was small
positive. CXR showed no consolidation. U/A was only significant
for glucose and ketones. He was started on an insulin gtt and
has received 3L NS and 10mEq of K thus far.
.
Currently, he has no complaints.
Past Medical History:
1. DM2: He was diagnosed 25 years ago. Within 1 year, he went
from oral hypoglycemics to insulin. His best HgbA1c was 11% more
than 5 years ago. He is not aware of any retinal complications
though his last eye exam was 3 years ago. He has been told he
has decreased kidney function intermittently. He has neuropathy,
though also has history of spinal cord injury.
2. Hypertension
3. Hyperlipidemia: He describes his blood as milky way.
4. Bipolar Disorder
5. History of PUD
6. Fatty liver disease
7. H/o meningitis in [**2160**], viral encephalitis in [**2161**] (prolonged
course), and recent transvere myelitis with urinary
incontinence, decreased BLE sensation and weakness, starting
last Tuesday and lasting for 4 days.
8. Chronic pancreatitis with pancreatic cysts
9. H/o spinal cord injury after falling out of a 10-[**Doctor Last Name **] in
[**2148**], with neck and back spasms requiring injections and
intermittent BLE weakness and neuropathy.
Social History:
Pt lives with his wife and 2 children. Between him and his wife,
they have 10 children. He is disabled since the spinal cord
injury. He smokes 1ppd x 24 years. He denies etoh, recreational
drug use.
Family History:
DM2, HL. Father with CABG at age 58, passed due to complications
of DM2. Mother with first MI at 65 yo.
Physical Exam:
ADMISSION PHYSICAL EXAM
General Appearance: Well nourished, No acute distress, No(t)
Overweight / Obese, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: NormocephaliC
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds
present, No(t) Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Not assessed, Tone:
Not assessed, decreased grip strength, 4+/5 BUE strength
otherwise, 4-/5 LLE, 4+/5 RLE, decreased sensation in feet
bilaterally, unable to elict DTRs
Pertinent Results:
On admission:
[**2163-9-20**] 10:26AM BLOOD WBC-10.6 RBC-4.87 Hgb-15.1 Hct-43.2
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.2 Plt Ct-254
[**2163-9-20**] 10:26AM BLOOD Neuts-72.0* Lymphs-19.6 Monos-4.3 Eos-3.3
Baso-0.9
[**2163-9-20**] 10:26AM BLOOD Glucose-525* UreaN-14 Na-134 K-4.7 Cl-94*
HCO3-23 AnGap-22*
[**2163-9-20**] 04:45PM BLOOD Calcium-8.1* Phos-2.4* Mg-1.6
Cholest-413*
[**2163-9-20**] 10:26AM BLOOD Triglyc-3344* HDL-54 CHOL/HD-11.1
LDLmeas-LESS THAN
On discharge:
[**2163-9-23**] 06:20AM BLOOD WBC-6.8 RBC-3.99* Hgb-12.3* Hct-35.9*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.3 Plt Ct-225
[**2163-9-21**] 10:26AM BLOOD Neuts-63.8 Lymphs-27.4 Monos-4.7 Eos-3.5
Baso-0.7
[**2163-9-23**] 06:20AM BLOOD Plt Ct-225
[**2163-9-23**] 06:20AM BLOOD Glucose-279* UreaN-24* Creat-0.6 Na-135
K-4.0 Cl-105 HCO3-26 AnGap-8
[**2163-9-23**] 06:20AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.8
[**2163-9-20**] 04:45PM BLOOD Triglyc-[**2077**]* HDL-39 CHOL/HD-10.6
LDLmeas-39
Brief Hospital Course:
Mr. [**Known lastname 84733**] is a 49 yo M with poorly controlled DM2, HTN, HL,
bipolar disorder who presented to the [**Hospital1 18**] ED with
hyperglycemia. He was admitted to the MICU on [**2163-9-20**]
for concern of diabetic kedoacidocis. On the following day, his
condition had stabilized and he was transferred to the floor. On
[**9-23**], he was discharged to home, in good condition, with
stable vital signs, ambulatory, and with appropriate outpatient
follow-up arranged. His brief hospital course was notable for:
.
#Hyperglycemia: Mr. [**Known lastname 84733**] [**Last Name (Titles) **] was notable for serum
glucose in the 500s, triglycerides in the 3000s, and a Hgb A1C,
of 14.5%, all consistent with very poorly controlled diabetes
mellitus. There was no evidence of infection or ischemia as a
precipitant of his [**Last Name (Titles) **]. The Pt was given IVF and
started on an insulin GTT, and admitted to the ICU. On the
insulin GTT, his serum glucose levels and anion gap quickly
resolved, and he was transitioned to SC insulin and transferred
to the floor. The [**Last Name (un) **] Diabetes serivice was consulted who
attempted different subcutaneous insulin regimens and ultimately
sent the Pt home on a regimen of 50 units of U-500 insulin TID
with meals, plus sliding scale coverage. [**Last Name (un) **] planned to
follow the patient as an outpatient, and he was discharged to
follow up with [**Last Name (un) **]. Of note, the [**Last Name (un) **] consultants were
suprised about how quickly the Pt's glucose levels resolved with
IV insulin, yet his need for very large amount of subcutaneous
insulin to control his glucose levels. They intended to
investigate this further as an outpatient, and this was
consistent with the history that the Pt had reported.
.
#Hypotension - The Pt presented with SBP 71 in the setting of
volume depletion and lisinopril therapy. The hypotension was
readily fluid-responsive, and the Pt remained normotensive
throughout the rest of his course. Culture data negative for
infection. No evidence of active bleeding.
.
#Hyperlipidemia: On admission the Pt was noted to have a
triglyceride level in the 3000s, which came down significantly
as his glucose control improved. Tricor monotherapy was
continued.
.
All other chronic medical issues for this patient were stable
and no changes were made to the patient's outpatient medication
regiment other than described as above. The Pt was discharged on
[**2163-9-23**] to follow-up with [**Last Name (un) **] as an outpatient in
good condition, with stable vital signs, ambulatory, and with
serum glucose levels between 150-300 on the discharge insulin
regimen.
Medications on Admission:
Gabapentin 600mg TID
Lisinopril 5mg daily
Lithium Carbonate 600mg [**Hospital1 **]
Nexium 20mg daily
Seroquel 300mg [**Hospital1 **]
Tricor 145mg daily
Humulin R U-500 sliding scale
(ASA 81 mg daily)
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lithium Carbonate 300 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO BID (2 times a day).
4. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
6. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: as
directed Injection four times a day: Please follow insulin
sliding scale as directed.
Disp:*qs 1 months supply* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetic Ketoacidosis
Secondary: Diabetes Mellitus, hypertension, hypertrigliceridemia
Discharge Condition:
Good, vital signs stable, ambulatory
Discharge Instructions:
You were admitted to the [**Hospital1 69**] on
[**2163-9-20**] after you were noted to have very elevated
blood sugars and triglycerides as a result of difficult to
control diabetes mellitus. You received a thorough evaluation
and treatment, including treatment with an insuling drip in the
medical ICU. After your condition stabilized, you were
transferred to a regular medicine floor. During your
hospitalization you were evaluated and followed by the [**Hospital **]
Clinic Diabetes service who made recommendations about your care
and will follow up with you as an outpatient. On [**2163-9-23**] your condition has improved, and you are being discharged
to home, to follow up with [**Last Name (un) **] as an outpatient.
.
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] directly to an emergency room
with any new or concerning symptoms. In particular, nausea,
vomiting, lightheadedness, weakenss, chest pain, shortness of
breath, fevers, chills, or any other new or concerning symptoms.
.
The following changes have been made to your medications:
**Insulin regimen:
You are being discharged on a regimen for U-500 insuling SS.
Please check fingersticks before breakfast, lunch, dinner, and
bedtime and follow the sliding scales below.
.
If fingerstick:
<100 do nothing
101-150 take 50 units (.10 cc); if at bedtime do nothing
151-200 take 55 units (.11 cc); if at bedtime take 5 units
(.01 cc)
201-250 take 60 units (.12 cc); if at bedtime take 10 units
(.02 cc)
251-300 take 65 units (.13 cc); if at bedtime take 15 units
(.03 cc)
301-350 take 70 units (.14 cc); if at bedtime take 20 units
(.04 cc)
351-400 take 75 units (.15 cc); if at bedtime take 25 units
(.05 cc)
>400 take 85 units (.17 cc); if at bedtime take 30 units
(.06 cc)
This information has also been provided for you in a sliding
scale chart.
.
Reminder: For the U-500 insulin, 50 units = 0.10 cc. You will
draw the syringe to the "10" mark
.
You have Diabetes Mellitus which has been very difficult to
control. It is very important that you follow the instructions
recommended by the [**Hospital **] Clinic team and attend all scheduled
outpatient appointments with them.
.
If is very urgent that you stop smoking. You should speak to
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 84734**] a smoking cessation
program.
Followup Instructions:
Please attend all follow-up appointments as scheduled.
.
It is very important that you call the [**Hospital **] [**Hospital 982**] Clinic to
check in with them and to schedule a follow-up appointment.
Please call them tomorrow at: ([**Telephone/Fax (1) 3537**]
.
Please make an appointment to follow-up with your primary care
doctor within the next 3 weeks.
ICD9 Codes: 4019, 2724, 3051, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4734
} | Medical Text: Admission Date: [**2163-3-28**] Discharge Date: [**2163-4-15**]
Service: [**Location (un) 259**] MEDICINE
CHIEF COMPLAINT: Shortness of breath and fever.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old
woman with history of moderate AF, paroxysmal atrial
fibrillation, hypothyroidism, dementia and essential
thrombocythemia who presents with shortness of breath and
fever. The patient is a resident of [**Hospital3 **] who was in her usual state of health until
approximately one week prior to admission when she noticed
cough and cold like symptoms. These symptoms worsened over
the following week. The cough productive of dark green
sputum. She was seen by a physician at the [**Hospital3 537**]
three days prior to admission. At that time she was treated
with nebulizers for presumed viral urinary tract infection.
However, her condition continued to deteriorate.
Specifically, she became more short of breath, reduced
exercise intolerance, worsening cough with productive sputum,
and decreased exercise tolerance. She was brought to the
[**Hospital1 69**] for further evaluation.
In the emergency department she was noted to be febrile to
102.3. Chest x-ray showed possible right upper lobe
pneumonia. The patient was treated with ceftriaxone and
azithromycin. She was also noted to be in rapid atrial
fibrillation and was started on a diltiazem drip.
PAST MEDICAL HISTORY: 1) Vertigo. 2) Moderate aortic
stenosis. 3) Paroxysmal atrial fibrillation. 4) History of
urinary tract infections. 5) Hypothyroidism. 6) Alzheimer's
with multi-infarct dementia. 7) Echocardiogram in [**6-/2162**] at
outside hospital showing normal left ventricular ejection
fraction, mild diastolic dysfunction, calcified aorta, mild
pulmonary hypertension, moderate aortic stenosis.
ALLERGIES: Question allergy to penicillin.
MEDICATIONS: [**Doctor First Name **] 30 mg b.i.d., Flonase q.d.,
multivitamin, Aricept 5 mg q day, hydroxyurea 500 mg q day,
hydrocortisone cream, metoprolol 12.5 mg b.i.d., Levoxyl 112
mcg q.d., Coumadin 2.5 mg q.d., Nizoral, Dilantin, Xalatan.
SOCIAL HISTORY: The patient has a very supportive family.
She currently lives in [**Hospital3 **] and is
capable of completing her anterior cruciate ligament without
assistance. She walks with a walker.
FAMILY HISTORY: Noncontributory.
ADMISSION LABORATORIES: Were notable for an INR of 4.6. Her
chem-7 was unremarkable. Her urinalysis was negative for
nitrates and leukocytes. Cardiac enzymes were negative.
Chest x-ray: Right upper lobe opacity consistent with
possible pneumonia. No congestive heart failure noted.
Bibasilar atelectasis.
EKG: Atrial fibrillation with ventricular rate greater than
100. No ST segment changes.
HOSPITAL COURSE: The patient was admitted to the medicine
service for further evaluation. She was alert and oriented
at time of admission. She was complaining of subjective
shortness of breath and was breathing at a respiratory rate
of approximately 20. She was saturating 85 to 95 percent on
2 liters by nasal cannula. She reported only minimal
improvement to nebulizer treatment. She was febrile in the
emergency department but remained afebrile on the floor. She
was started on Levofloxacin for treatment of her pneumonia.
On day of admission the resident and intern were called to
see the patient at approximately 2 P.M. for tachycardia and
shortness of breath. The patient had been titrated off her
diltiazem drip which had been started in the emergency
department. She was maintained on metoprolol. At the time
the intern and resident examined the patient she was satting
95 percent on 2 liters by nasal cannula. A repeat chest
x-ray was unchanged from prior with no signs of congestive
heart failure. It was felt that the patient was stable at
this time. Her elevated heart rate was transient and was
treated by increasing her metoprolol dose. She was noted to
be again in atrial fibrillation. Then again at 7 P.M. the
intern was called to see the patient for increased confusion.
At that time the patient was noted to have labored breathing.
A pulse oximeter measured her O2 saturation to be
approximately 65. She was started on a nonrebreather. An
arterial blood gases was obtained which showed a pCO2 of 109,
a pO2 of 102, and a pH of 7.06. Calculated sodium bicarb was
33 percent. The patient had a repeat chest x-ray obtained.
This showed some mild congestive heart failure. The Medical
Intensive Care Unit team was notified and the patient was
transferred to the Intensive Care Unit. The family was also
notified. The patient's daughter stated that she wanted her
mother to be DNR/DNI. Again the patient was supertherapeutic
on Coumadin with an INR of 4.6. She was reversed with
vitamin K. Patient's hydroxyurea therapy was discontinued
while in the Medical Intensive Care Unit. She was started on
cefepime, Vancomycin and levofloxacin for treatment of her
pneumonia. The patient was reversed with vitamin K and a
PICC line was placed. She continued to improve over the
following days. Her heart rate was controlled with
intravenous metoprolol and/or Lopressor. All cultures both
blood and urine remained negative during her hospital course.
The patient was transferred to the floor for further
management on [**2163-4-4**]. The patient was transitioned to
p.o. medications. Speech and swallow evaluation was
conducted which revealed that the patient tolerated thick and
liquids well. She was continued on antibiotics for a ten day
course. After discontinuing of her antibiotics the patient
had increasing white blood cell count. She was also noted to
have very mild low grade fevers and very minor change in
mental status. Patient was then restarted on antibiotics and
the CT scan was obtained of her chest. The CT scan was
relatively unremarkable but did show possible early
pneumonia. The patient was continued on a seven day course of
cefepime, Vancomycin. Upon completing this course the
patient remained afebrile and remained alert and oriented.
Prior to discharge her mental status continued to improve.
Her course was also complicated by renal insufficiency with
increase in her creatinine to 2.3 from a baseline of 0.7.
This was felt to be due to a transient episode of
hypotension. Her creatinine began to improve again prior to
discharge and was 1.8 at time of discharge.
OVERALL IMPRESSION: This is a [**Age over 90 **] year-old female with a past
medical history significant for central thrombocytosis,
moderate atrial fibrillation and congestive heart failure.
who presented with worsening shortness of breath and
tachycardia. It was believed that the patient's pneumonia
worsened her atrial fibrillation causing her to have an
increase in heart rate. This in turn caused the patient to
go into decompensated congestive heart failure requiring a
Medical Intensive Care Unit stay with aggressive diuresis.
The patient was treated for pneumonia with antibiotics. Her
course was complicated by an episode of renal insufficiency
which was resolving by time of discharge. The patient was
tolerating good p.o. intake and was cleared by speech and
swallow on the day of discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Essential thrombocytosis off hydroxyurea.
2. Congestive heart failure likely secondary to diastolic
dysfunction in rapid atrial fibrillation.
3. Pneumonia.
4. Aortic stenosis.
5. Atrial fibrillation.
6. Hypothyroidism.
DISCHARGE MEDICATIONS:
1. Donepezil 5 mg p.o. q.h.s.
2. Multivitamin 1 cap p.o. q.d.
3. Calcium carbonate 500 mg p.o. t.i.d.
4. Vitamin D 400 units p.o. q day.
5. Latanoprost 0.005 percent ophthalmic solution.
6. Hydrocortisone cream.
7. Ipratropium neb p.r.n.
8. Tylenol p.r.n.
9. Docusate 100 mg p.o. b.i.d.
10. Bisacondyl 10 mg p.o./p.r. q d p.r.n.
11. Fexofenadine 60 mg p.o. q.d.
12. Benzonatate 100 mg p.o. t.i.d. p.r.n. cough.
13. Levothyroxine 112 mcg p.o. q.d.
14. Olanzapine 5 mg p.o. q.d. p.r.n.
15. Miconazole powder t.i.d. p.r.n. to buttocks.
16. Albuterol neb p.r.n. shortness of breath.
17. Metoprolol 25 mg p.o. t.i.d.
18. Warfarin 3 mg p.o. q.h.s.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2163-4-15**] 14:29
T: [**2163-4-15**] 14:42
JOB#: [**Job Number 55153**]
ICD9 Codes: 486, 4280, 5180, 4241, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4735
} | Medical Text: Admission Date: [**2160-1-15**] Discharge Date: [**2160-1-30**]
Date of Birth: [**2111-11-26**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 41841**] is a 48 year old
female with end stage liver disease secondary to alcohol
abuse who, after complete transplant evaluation, was found to
be a candidate for a liver transplant. Her sister, [**Name (NI) **]
[**Name (NI) 6483**], went under a complete evaluation and was found to
be a suitable volunteer donor on [**2160-1-15**]. The
patient presented to [**Hospital1 69**] for
a living related liver transplant. Operative risks and
complications were reviewed in full prior to the operation.
PAST MEDICAL HISTORY:
1. Liver cirrhosis secondary to ethanol. She had a history
of intermittent hepatic encephalopathy.
2. Gastroesophageal reflux disease.
3. Hypothyroidism.
PAST SURGICAL HISTORY:
1. Status post right lumpectomy.
ALLERGIES: Penicillin, codeine, Levofloxacin.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q. day.
2. Aldactone 100 mg p.o. q. day.
3. Nadolol 20 mg p.o. q. day.
4. Lasix 40 mg p.o. twice a day.
5. Colace.
6. Regular multivitamin.
7. Vitamin B12 and folate.
8. Synthroid 0.025 micrograms p.o. q. day.
PHYSICAL EXAMINATION: On admission, vital signs were
stable. In general, she was awake, alert and oriented. She
appeared chronically ill. Skin was notable for occasional
spider angiomata and palmar erythema. Head, Ears, Eyes, Nose
and Throat: Normocephalic, atraumatic. Extraocular
movements intact. Sclerae is mildly icteric. Neck was
without any lymphadenopathy or thyromegaly. Lungs were clear
to auscultation bilaterally. Heart was regular rate and
rhythm; no S3, S4, murmurs or rubs were appreciated. Abdomen
soft, nontender, no hepatosplenomegaly and no ascites. There
is a well healed subcostal skin incision from a prior open
cholecystectomy. Extremities were without any peripheral
edema. Neurologically, she was grossly intact.
LABORATORY: On admission, white blood cell count 5.9,
hematocrit 28.4, platelets 140. Sodium 149, potassium 4.9,
chloride 106, bicarbonate 25, BUN 8, creatinine 0.7, glucose
100. ALT 16, AST 33, alkaline phosphatase 142. Total
bilirubin 1.8.
BRIEF SUMMARY OF HOSPITAL COURSE: [**First Name8 (NamePattern2) **] [**Known lastname 41841**] is a 48 year
old female with end stage liver disease secondary to alcohol
abuse. She presented to [**Hospital1 69**]
on [**2160-1-15**], for a living related liver transplant
from her sister, [**Name (NI) **] [**Name (NI) 6483**]. The procedure went
without any complications.
The patient underwent a liver transplant with a three duct
anastomosis to a Roux-en-Y hepatica-jejunostomy (segment 6,
anterior duct, superior duct). Immediately postoperatively,
the patient was transferred to the Surgical Intensive Care
Unit for close monitoring. She, at that point, received a
total of nine units of packed red blood cells, 14 units of
fresh frozen plasma, 5 units of platelets and one
cryo-precipitant. Her postoperative hematocrit was stable at
that point at 35.
She was weaned and extubated postoperative day one. Lasix
was given to diurese excess fluid. She had initially been
placed on a heparin drip in addition to aspirin as well as
Plavix given that there were three arterial anastomoses to
assist with patency.
Initial ultrasound visualized all three arteries and there
was a question of some flattened wave forms. The ultrasound
was later repeated and they were able to visualize normal
venous as well as arterial blood flow. The ducts remained
patent.
On postoperative day number four, the patient was noted to
have a decrease in her hematocrit from 34 to 28, and given
that the patient was on several blood thinners, an ultrasound
was obtained to later reveal the 3 by 3 centimeter hematoma.
She continued to require several units of packed red blood
cells. It was decided at this point to take the patient back
to the Operating Room for further exploration, wherein they
were able to evacuate an intra-abdominal hematoma in the
right upper quadrant. From that point on, serial hematocrits
as well as coagulation studies were performed and therein,
the patient remained hemodynamically stable until the day of
discharge.
Post re-exploration prompted us to obtain another ultrasound
which was normal. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were removed and
after a T-tube study was performed postoperatively, all three
T-tubes were capped. For immunosuppressants, the patient was
started on CellCept p.o. twice a day. She was placed
initially on a Solu-Medrol taper and then changed to
Prednisone 15 p.o. q. day. The cyclosporin dose was adjusted
according to level. She received a total of two doses of
Simulect during her hospitalization.
Her transaminases had been trending downward to within normal
limits by the day of discharge. Her total bilirubin reached
a peak of 13.7 before it began to trend downward to a level
of 10.4 on the day of discharge.
The patient's diet was slowly advanced which she tolerated.
The patient's pain was well controlled with p.o. medications.
It was felt that the patient was stable for discharge on
postoperative day 15 and 11. Follow-up at the Transplant
Center with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She was discharged home with
Visiting Nurses Association services.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. End stage liver disease secondary to alcohol abuse;
postoperative hematoma.
2. The patient is status post living related liver
transplant / excellent graft function.
3. Postoperative hematoma status post evacuation.
4. Anemia requiring several units of packed red blood cells.
DISCHARGE MEDICATIONS:
1. Camphor menthol, one application topically three times a
day p.r.n.
2. Plavix 75 mg, one tablet p.o. q.day.
3. Aspirin 81 mg, one tablet p.o. q. day.
4. Fluconazole 400 mg, one tablet p.o. q. day.
5. CellCept [**Pager number **] mg, one tablet p.o. twice a day.
6. Bactrim-SS, one tablet p.o. q. day.
7. Prednisone 15 mg, one tablet p.o. q. day.
8. Percocet, one to two tablets p.o. q. four to six hours
p.r.n. pain.
9. Pantoprazole 40 mg, one tablet p.o. q. day.
10. CellCept [**Pager number **] mg one tablet twice a day.
11. Valcyte 450 mg, one tablet p.o. q. day.
12. Lasix 20 mg, one tablet p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to have [**Hospital1 **]-weekly laboratory studies drawn
which should include CBC, Chem-10, liver function tests,
amylase, lipase, albumin, cyclosporin level in the morning
before the a.m. dose is given, as well as coagulation
studies.
2. She will be discharged with Visiting Nurses Association
services for wound care, nursing, blood checks, medication
review, as well as biweekly labs.
3. She is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the
Transplant Center at the [**Last Name (un) 2443**] Building, [**Telephone/Fax (1) 673**], on
[**2160-2-6**], at 01:00 p.m.
4. She is additionally to follow-up with Dr. [**First Name (STitle) **] at the
Transplant Center on [**2160-2-11**], at 02:30 p.m.
5. She is to follow-up with Dr. [**Last Name (STitle) **] on [**2160-2-20**],
at 01:40 p.m.
For any additional appointment she is to call the Transplant
Center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 12276**]
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2160-1-30**] 18:06
T: [**2160-2-4**] 23:37
JOB#: [**Job Number 49071**]
ICD9 Codes: 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4736
} | Medical Text: Admission Date: [**2110-5-2**] Discharge Date: [**2110-5-7**]
Service: MEDICINE
Allergies:
Ibandronate Sodium / Actonel / Hydrochlorothiazide
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 11740**] is a [**Age over 90 **] yo female with a history of HTN who
presents with SOB and fever. She went to her PCP yesterday with
complaint of several days of SOB and non productive cough. She
did not have wheezes and was not hypoxic. She was given
amoxicillin for suspected bronchitis. Tonight she presented to
the ED due to progressive respiratory distress.
.
In the ED, initial vs were: T 101.5 HR 88 BP 160/110 RR24
O2Sat:100. The patient was tachypneic and very wheezy despite no
COPD/asthma history. She received nebs and methylprednisolone. A
chest X ray showed an opacity so she was given ceftriaxone and
levofloxacin. Given poor response to above, she was placed on
BiPAP and was noted to have a breif episode of hypotension to
the 70s which resolved with 500 cc NS bolus. She was sent for a
CTA, which revealed a moderate pericardial effusion showing
effusive constrictive pattern but no tamponade. An echo was
obtained which showed a moderate pericardial effusion without
signs of tampenade. The patient also had a run of SVT to 150s,
which converted with adenosine. She also complained of some
intermittient abdominal discomfort, but her abdomen was soft and
she was guaiac negative. Vitals prior to transfer were: 99
136/78 24 100% on 100% FiO2 BiPAP
.
On review of systems, she states that she fell out of her bed 3
days ago due to "weakness." She denies hitting her head or
hurting herself, but was on the floor for a while before she
could get help. She also admits to poor PO intake due to
anorexia and chills for the last week. She denies any chest
pain, palpitations (even in the ed witht the SVT), syncope,
orthopnea, ankle edema, prior history of deep venous thrombosis,
pulmonary embolism, myalgias, black stools or red stools.
.
Past Medical History:
1. HTN
2. ?RA
3. osteoporosis, T9 compression fx
4. GERD
5. hemorrhoids
6. depression
7. sciatica
Social History:
Non-smoker. Denies Etoh. Independent with ADLs. Lives alone.
Daughter lives nearby.
Family History:
Denies significant cardiac history. Sister had liver cancer
Physical Exam:
Vitals: T: 98.4 BP: 159/102 P: 99 R: 28 O2: 100% on bipap
pulsus 10 mm hg
General: Alert, oriented, no acute distress, biPAP mask in place
HEENT: Sclera anicteric, mouth not examined, fine jaw tremor
Neck: JVD difficult to assess given mask and fine jaw tremor
Lungs: no wheezes or rhonchi, bilateral rhales
CV: Regular rate and rhythm, normal S1 + S2, extra heart sounds
difficult to appreciate over the sound of the bipap machine
Abdomen: + BS, soft, non-distended, tenderness to deep palpation
in RLQ, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2110-5-2**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade. No right
ventricular diastolic collapse is seen. The echo findings are
suggestive but not diagnostic of pericardial constriction.
IMPRESSION: Moderate circumferential pericardial effusion
without echocardiographic signs of tamponade.
[**2110-5-2**] CXR:
FINDINGS: Portable upright AP view of the chest is obtained.
Clips are noted in the right upper quadrant. Low lung volumes
limit evaluation, as does the portable AP technique. The heart
appears mildly enlarged allowing for technical limitations.
Small bilateral pleural effusions are noted. There is slight
increase in retrocardiac opacity may represent atelectasis
versus early pneumonia. There is note made of Kerley B lines
suggesting mild fluid overload. Mediastinal contour is
prominent, which may be related to unfolded thoracic aorta.
Degenerative changes are severe at both shoulders. There is a
dextroscoliosis of the thoracolumbar spine, apex along the upper
lumbar spine.
IMPRESSION: Cardiomegaly, mild fluid overload, small bilateral
pleural
effusions. Probable left lower lobe atelectasis, less likely
pneumonia.
[**2110-5-2**] CTA:
IMPRESSION:
1. Large pericardial effusion, apparently new compared to chest
radiograph
[**2109-2-5**].
2. No evidence of pulmonary embolism.
3. Mediastinal lymphadenopathy, possibly related to hydrostatic
edema but
not specific for this process.
4. Mild hydrostatic edema, with small bilateral pleural
effusions, left
slightly larger than right.
5. Scattered sub-4-mm pulmonary nodules. Given the patient's
advanced age,
follow- up is likely not warranted if there is no history of a
primary
malignancy.
6. Focal opacity in the right lung apex, which appears to have
been present on chest radiograph of [**2109-2-5**], and most likely
reflects a scar. However, serial chest radiographs could be
considered to exclude indolent infection if warranted
clinically.
Brief Hospital Course:
Ms. [**Known lastname 11740**] is a [**Age over 90 **]yo F with past medical history of HTN and
recent symptoms of cough, weakness, and anorexia who presented
to the ED with fever and SOB and was found to have pericardial
effusion and atypical cells on diff suggestive of blasts.
.
# Acute leukemia: Patient's initial labs showed anemia,
thrombocytosis, and leukocytosis which was concerning for
hematological malignancy. Her diff showed 40 "other" cells
which were eventually found to be blasts. She was also found to
have a pericardial effusion which was thought to be malignant.
Heme/onc was consulted and - given the patient??????s age and poor
prognosis with leukemia - a family meeting was held to determine
whether or not she should have a confirmatory bone marrow biopsy
and undergo chemotherapy. It was decided not to undergo a bone
marrow biopsy and chemotherapy was not consistent with her goals
of care. It was decided that the patient would go to her
daughter's home with hospice.
.
# Pericardial effusion: In the ED the patient underwent CTA for
her dyspnea and was found to have evidence of moderate sized
pericardial effusion. She underwent bedside echo which
confirmed this. Pulsus paradoxus was not elevated at 10 mm hg
and she had no evidence of hemodynamic compromise (although she
did have transient hypotension in the ED that was responsive to
a small bolus of IV fluids). The initial differential diagnosis
included malignant versus infective pericarditis with effusion.
Uremic or autoimmune disease was less likely given no history of
autimmune disease and normal BUN. Given the presence of blasts
on peripheral blood, and no ST changes on EKG or elevated
troponin, it was thought that the effusion was most likely
malignant. Heme/Onc was consulted and it was decided not to
pursue fluid diagnosis with pericardiocentesis given comfort
goals as stated above.
.
# Shortnes of breath: The patient presented with complaint of
worsening dyspnea. Her chest x ray showed evidence of
cardiomegally with widened mediastinum and cephalization of
blood vessels and peribronchial cuffing consistent with
pulmonary vascular congestion. This was thought to be due to
poor forward left ventricular ejection possibly due to the
pericardial effusion versus diastolic dysfunction. She was
started on BiPAP as she was hypoxic, and this improved her O2
sats and tachycardia. She was weaned overnight to O2 by nasal
cannula. She was also found to be febrile to 101 in the ED so
she was given levofloxacin. This was continued initially, but
was stopped in the CCU as the patient was no longer febrile and
it was not thought that she had a pneumonia, but rather the
fever was from her malignancy. She was given lasix 10mg IV ONCE
which resulted in nearly 800cc output over a few hours. This
improved her respiratory status, she was weaned to NC and
remained comfortable on the floor.
.
# Hyponatremia: The patient was found to be hyponatremic on
admission with sodium of 122. Pt had history of hypnatremia in
[**2107**], but this was thought to be from appropriate ADH in setting
of overdiuresis with HCTZ. However, she was not on any
diuretics prior to this admission. Fena was 2.5 which did not
support hypovolemic hyponatremia. Clinically she appeared
hypervolemic, therefore it was thought that she may have SIADH
likely due to malignancy.
.
# Hyperkalemia: The patient was found to have an initial
potassium of 5.6. Her EKG showed no evidence of peaked T waves
or prolonged PR or QRS. Etiology was unclear as her creatinine
normal and she was not on diuretics. Her urine potassium
excretion was unrevealing. It was thought that she may have
pseudohyperkalemia in the setting of thrombocytosis (which
corrects at 0.15 per 100K platelets above normal) however,
hyperkalemia resolved while her platelets were still elevated
which does not support this.
.
# Anemia: Hct was 27.9 which was 10 points lower than it was in
[**1-8**]. Iron studies were consistent with anemia of chronic
inflammation. Hemolysis labs were unimpressive. It was thought
that her anemia was likley from her malignancy. She was
transfused 1 unit of RBCs.
.
# Thrombocytosis: the patient was found to have 717, 000
platelets. This was also thought to be secondary to her
underlying malignancy.
.
# AVNRT: The patient had an episode of SVT in the ED that looked
like AVNRT on EKG. She was given atropine which converted the
tachyarrhytmia to sinus. The patient was monitored on telemetry
and had no other events.
.
# Hypertension: The patient's atenolol was initially held in the
setting of uncertaintly regarding her hemodynamic state with the
pericardial effusion. However, she remained hemodynamically
stable so her atenolol was restarted the following morning.
Medications on Admission:
ATENOLOL - 25 mg PO Q day
CITALOPRAM - 10 mg PO Q day
COLCHICINE - 0.6 mg PO Q day
GABAPENTIN - 300 mg Capsule - PO Q HS
NABUMETONE - 500 mg PO Q day (arthritis)
ACETAMINOPHEN - 650 mg PO BID PRN
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] PO Q day
CAPSAICIN - (OTC) - 0.1 % Cream - PRN (arthiris)
MULTIVITAMIN PO Q day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg EC PO Q day
WHEAT DEXTRIN [BENEFIBER CLEAR SF (DEXTRIN)] - (OTC) - 3
gram/3.5 gram Powder - 1 tablespoon Powder(s) by mouth once a
day
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for fever, pain.
6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Hospice
Discharge Diagnosis:
Primary:
1. New leukemia
2. Pericardial Effusion
3. Heart Failure Exacerbation
4. AVNRT
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:
Mrs. [**Known lastname 11740**], it was a pleasure taking care of you during your
stay at [**Hospital1 18**]. You were initially admitted with shortness of
breath and fever. In the emergency room you were treated for
pneumonia, but required IV fluids due to low blood pressure,
bipap for help with breathing and were found to have fluid that
had built up around your heart. At first you were admitted to
the Cardiac Care Unit for closer monitoring, during this time it
was discovered that you likely had a new diagnosis of leukemia.
After discussion with hematology/oncology and your family, you
decided that you did not want to pursue further testing or
treating. Your breathing improved and your blood pressure got
better and you were safe for transfer to the medicine floor.
After discussion with the palliative care specialists, you and
your family decided that you would go home with hospice. The
hospice nurses and doctors [**Name5 (PTitle) **] help control your symptoms and
manage your medications at home.
Followup Instructions:
Patient will have close follow up in home via hospice care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 486, 2761, 2767, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4737
} | Medical Text: Admission Date: [**2170-8-14**] Discharge Date: [**2170-8-22**]
Date of Birth: [**2089-12-10**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Cyclosporine / Clindamycin / Meropenem /
Metronidazole
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o female with h/o MDS transformed to AML tranferred from
[**Hospital Unit Name 153**] following an admission for SOB.
.
Presented to the ER [**8-14**] with SOB. Patient was found to have a BP
of 220/80. She was given 40mg PO lasix and [**12-11**] inch of
nitropaste, which quickly brought her BP down to 100/50. Her VS
at the time were notable for a temp 97.8, HR 96, and a RR of 44
(O2 sats were not documented). She then became tachycardic, with
a HR of 136. She was given 0.5mg ativan PO for anxiety which
then caused her BP to drop further to 80s/50s. Her pulse
gradually slowed, down to 96 and then down to 62. However, her
BP remained 80s/50s. Ms. [**Known lastname 60949**] appeared diaphoretic and
continued to be tachypneic, with RR in the 40s. O2 sats dipped
down to 86% but then came up to 94% on 6L O2.
.
In the ER, no temp was checked, but pt was 89% on RA on arrival,
with a RR of 18. Sats improved to 93-94% on 3L by nc (is on 2L
at home). BP was 84-129/40-58 and HR 62. Her PAC was accessed
for blood draw. She was given lasix 40mg IV x1 and a foley was
placed to monitor UOP. She was also started on a nitro gtt at
10mcg/min. She was started on BiPAP with improvement in her
tachypnea. By the time she was transferred to the [**Hospital Unit Name 153**], her BP
was in the 120s/80s and her RR was 17.
.
Of note, the pt's functional status has been slowly declining
over the recent months. Per her daughter, the patient has even
mentioned stopping transfusions at times because they seem to be
causing her to develop more episodes of CHF. At her baseline the
patient can walk a few steps with a walker but must stop [**1-11**]
fatigue and dyspnea. She is essentially limited to movements in
her room at [**Hospital 100**] Rehab (gets up to commode, up to the chair,
etc).
.
in the [**Hospital Unit Name 153**] the patient was briefly on BIPAP and then weaned to
NC. She was given lasix for presumed CHF flare. When she was
stable off BIPAP she was transferred to the floor for further
management.
Past Medical History:
Past Medical History:
Onc history: Mrs. [**Known lastname 60949**] was diagnosed with MDS
in [**2169-9-9**] after a greater than 6 year history of anemia
treated with iron supplementation. In [**7-14**] [**Known firstname **] became more
fatigued and irritable and was noted to be pancytopenic. Bone
marrow biopsy at that time showed: hypercellular for age bone
marrow erythroid hyperplasia, moderately dysplastic
granulopoiesis, mildly increased myeloblasts, megaloblastic and
dysplastic erythropoiesis, abundant megakaryocytes wtih frequent
small hypolobate dysplastic forms, decreased stainable iron, no
ring sideroblasts seen, and mild to focally moderatley increased
bone marrow reticulin. Her biopsy and aspirate were consistent
with a myelodysplatic disorder. Cytogenetics show multiple
abnormalities including a deletion of the long arm of chromosome
5 and trisomy 8. She has been receiving blood product support
now
for several months requiring transfusions 1-3 times weekly of 1
bag of platelets and [**12-11**] units PRBC. She last received blood
products on [**2170-7-20**] of 1 bag of platelets.
.
PAST MEDICAL HISTORY:
AML- supportive tx only (no chemo/radiation)
s/p fall [**12/2169**] sustaining a right trimalleolar fracture
CHF- [**2170-4-9**]
Paroxysmal Afib
bradycardia
Colon Cancer- no radiation or chemotherapy
Depression
UTI [**5-15**]
Urinary urgency/incontinence
Stoma bleeding- [**2170-4-9**]
.
PAST SURGICAL HISTORY
s/p colectomy with colostomy [**2163**]
s/p pacer placement for bradycardia [**5-14**]
s/p insertion of port-o-cath [**3-15**]
Social History:
[**Known firstname **] was born in Moldova but for a period of her childhood her
family was in exhile in Siberia. She emigrated to [**Country **] in
[**2143**] and then to the USA in [**2159**]. She continued to spend [**1-12**]
months a year in [**Country **] until this past winter. She worked for
about 50 yrs in both [**Country 532**] and [**Country **] as a math teacher. She
speaks [**Hospital1 100**] and Russian fluently. She does not speak English.
She never smoked or drank alcohol.
Family History:
[**Known firstname 60950**] father is deceased- died in [**2105**] in Russian
concentration
camp with kidney problems. [**Name (NI) **] mother died of a stroke in [**2127**].
She has two children: a son and a daughter who are both alive
and
well.
Physical Exam:
VS - T 99.3 P 67 BP 140/60 RR 30 O2sat 95% 5L NC
Gen: Elderly female, Russian only speaking, thin female, in mild
resp distress.
HEENT: Sclera anicteric, MMM. Neck supple, no evidence of JVD.
Lungs: Crackles [**12-11**] way up lungs bilaterally, no wheezes, poor
resp. effort
CV: RR, normal S1 and S2, no m/r/g.
Abd: Soft, NTND. + hernia around ostomy site. Colostomy bag in
place, no stool currently. + quiet BS. No masses, no HSM
appreciated.
Ext: no edema, 2+ PT/radial pulses
Pertinent Results:
Labs on admission:
[**2170-8-14**] 03:30AM BLOOD WBC-12.6*# RBC-3.29* Hgb-10.0* Hct-27.5*
MCV-84 MCH-30.5 MCHC-36.5* RDW-14.7 Plt Ct-13*#
[**2170-8-14**] 03:30AM BLOOD Neuts-4* Bands-0 Lymphs-6* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-3* Blasts-81*
[**2170-8-14**] 03:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-8-14**] 03:30AM BLOOD Plt Smr-RARE Plt Ct-13*#
[**2170-8-14**] 03:30AM BLOOD Glucose-97 UreaN-41* Creat-1.7* Na-131*
K-3.8 Cl-93* HCO3-27 AnGap-15
[**2170-8-14**] 03:30AM BLOOD CK(CPK)-26
[**2170-8-14**] 03:30AM BLOOD cTropnT-0.07*
[**2170-8-14**] 03:30AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0
[**2170-8-14**] 09:07AM BLOOD Type-ART pO2-141* pCO2-41 pH-7.47*
calTCO2-31* Base XS-6.
.
[**2170-8-14**] CXR - A pacemaker overlies the left chest, with leads
overlying right atrium and right ventricle. There is a right
internal jugular central venous catheter in place, with the tip
in the proximal right atrium. The cardiac and mediastinal
contours are unchanged, with aortic calcifications.
Moderate-to-severe congestive failure persists. There is likely
a left effusion. No pneumothorax. IMPRESSION: Persistent
moderate-to-severe congestive failure. An underlying pneumonia
cannot be excluded
Brief Hospital Course:
80 yo f with MDS recently tranformed to leukemia presented from
[**Hospital 100**] Rehab after acute onset SOB likely due to CHF
exacerbation with possible PNA as well.
.
On admission the patient had evidence of volume overload on CXR
an on exam. However, PNA couldn't be excluded either. It was
thought that there may also have been a component of
leukocytosis contributing to her resp distress as well given her
CBC showing 80% blasts. The patient's SOB was very responsive to
nitropaste so she was started on 1 inch q6h with good effect.
She was also given lasix IV boluses as needed for SOB. For her
possible leukocytosis she was given hydrea, 500mg x1 and 1000mg
x1. Although she responded to diuresis, given her refractory
leukemia she remained transfusion dependent and unfortunately
with transfusion would become overloaded with worsening
respiratory status. She continued to complain of SOB and she
began to require morphine IV to make her breathing more
comfortable. She was continued on Nitropaste and given morphine
as needed for comfort. When it became clear that the patient
would continue to require more and more transfusion support and
her respiratory status was not improving, a family meeting was
arranged to discuss the goals of care. She had elected not to
pursue any aggressive treatment up to this point. It was
explained to the patient and the family that the patient would
continue to need transfusion support which would likely worsen
the patient's respiratory status and make it difficult for her
to return to her nursing home. After a long discussion, the
patient elected to stop getting transfusion support with goal of
comfort only. She was made CMO and was continued on IV morphine
and nitropaste as needed. Her daughter and grandson were at the
bedside most of the time. When she became CMO her antibiotics
were discontinued and labs were no longer checked. She passed
away on the morning of [**8-22**] with her daughter and grandson
present.
Medications on Admission:
tylenol 650mg PO Q4prn
amiodarone 200mg PO QD
docusate 100mg PO BID
heparin flushes to port
latanoprost 0.005% 1drop OU QHS
lorazepam 0.5mg PO TID prn
pantoprazole 40mg PO QD
valerian 1mg PO QHS
senna 1tab PO BID prn
MOM 30mL PO QD prn
lasix 20mg IV prn
benadryl 25mg q6 PO prn
melatonin 3mg PO QHS
trazadone 50mg PO QHS prn
hydrocortisone 2.5% CR appy to affected area [**Hospital1 **]
venlafaxine XR 75mg PO QD
metoprolol tartrate 25mg PO BID
hydralazine 10mg PO TID
isosorbide mononitrate 30mg PO QD
anzemet 12.5mg IV Q8
lasix 40mg PO QD
levofloxacin 250mg PO QD (start [**8-9**] -> [**8-16**])
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 4280, 486, 5849, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4738
} | Medical Text: Admission Date: [**2164-4-5**] Discharge Date: [**2164-4-17**]
Date of Birth: [**2088-1-27**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
Past Medical History:
HTN
Type 2 diabetes mellitus
ESRD
Depression
Multifactorial anemia.
Family History:
NC
Physical Exam:
On transfer to medicine service:
Afebrile 120/70 80 12 98% on 2L NC orthostatics +
AOx3, frail elderly female, NAD
RRR nl S1S2
bilateral crackles at bases
sNTND, BS+
1+ bilateral LE edema.
Pertinent Results:
[**2164-4-5**] 12:23PM WBC-14.3* RBC-5.31 HGB-12.7 HCT-42.0 MCV-79*
MCH-24.0* MCHC-30.3* RDW-20.9*
[**2164-4-5**] 02:14PM TYPE-ART PO2-60* PCO2-46* PH-7.25* TOTAL
CO2-21 BASE XS--6 COMMENTS-LACTATE AD
[**2164-4-5**] 04:34PM TYPE-ART PO2-148* PCO2-51* PH-7.24* TOTAL
CO2-23 BASE XS--5
Brief Hospital Course:
Initial evaluation showed a traumatic subarachnoid hemmorrhage.
Neurosurgery consulted on the patient and did not intervene
surgically as there was no evidence of aneurism present. She was
followed medically with clinical and radiographic improvement.
Follow-up MRI/MRA confirmed the abscence of an occult arterial
aneurysm, or other pathology.
During her hospital course, she had multiple syncopal episodes.
The patient repeatedly had + [**Last Name (LF) 43789**], [**First Name3 (LF) **] she was volume
recussitated and her antihypertensive regimen was pared down to
balance blood pressure control and decrease in orthostatic
symptoms. She was monitored on telemetry during the syncopal
episodes with no evidence of arrythmia. She was also ruled out
for MI as an etiology of her syncope.
THe patient has end stage renal disease and is scheduled to have
an AV fistula placed as an outpatient. She will follow up with
her PCP and nephrologist for further coordination of care.
She was also found to have anemia of chronic disease. Stool
guiacs were negative.
During her hospital stay she also was found to have a UTI for
which she was started on antibiotics, and she had multiple
episodes of diarrhea (which she has had for >2 years), which
were c. diff negative so she was started on loperamide prn.
Medications on Admission:
unknown initially.
Discharge Medications:
1. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO QD (once a
day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
4. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Anagrelide HCl 1 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
7. Advair Diskus 100-50 mcg/DOSE Disk with Device Sig: One (1)
activation Inhalation twice a day: resume home dose if
different.
8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QD (once a day) for 3 days.
10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO every
4-6 hours as needed for Diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
SAH (subarachnoid hemorrhage)
SDH (subdural hemorrhage)
HTN
orthostatic hypotension with syncope (passing out)
Type 2 diabetes mellitus
ESRD
depression
anemia due to renal disease
microcytic anemia
mild hyperkalemia (high potassium)
mild hypoglycemia
Discharge Condition:
stable.
Discharge Instructions:
Take all medications as prescribed. The doses of some of your
medications have been changed, please note the changes and take
accordingly.
Call your doctor or come to the ER if you feel lightheaded or
have trouble walking, or if you have worsened headache or neck
pain, fevers, or changes in your vision.
Your kidneys do not excrete potassium easily. It is important
to avoid bananas, [**Location (un) 2452**] juice, potatoes, and other foods high
in potassium.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 125**] K. [**Telephone/Fax (1) 2731**] Call to schedule
appointment -- you should have your blood rechecked for your
mildly high potassium by next week, earlier if you are not
taking lasix.
Follow up with your primary care physician. [**Name10 (NameIs) **] to schedule an
appointment for later this week. Once you have completed the
course of treatment for the urinary tract infection, he will
arrange for fistula placement.
Completed by:[**2164-4-27**]
ICD9 Codes: 4280, 496, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4739
} | Medical Text: Admission Date: [**2102-9-4**] Discharge Date: [**2102-9-13**]
Date of Birth: [**2027-6-27**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Called by Emergency Department to evaluate
IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 75 year-old right-handed woman with a history of
HTN and depression who presents with a headache and left sided
weakness, found to have a large (5x5x7cm) right temporal lobe
hemorrhage. According to her husband, ~1 week ago the patient
was complaining of a headache, as well as the sensation that she
had 'funny lines' in her left eye. She went to see her
ophthalmologist, who found no abnormalities, but thought this
may
be secondary to a migraine headache (though according to her
husband she has no history of migraines). The vision changes
and
headache improved, and later that week she had a routine
physical, which reportedly showed a 'normal' blood pressure, and
no other abnormalities. Today her husband reports that around
noon she began complaining of a severe headache. Shortly after
that he noticed that she was having trouble keeping her balance,
and fell down in the living room. Around this time she vomited,
and also was incontinent of stool. Her husband initially just
left her on the floor, as he thought she had 'a stomach bug' and
was going to let her rest. After ~30 minutes, when she didn't
get up, he tried to help her up. He reports he struggled with
her for ~1 1/2 hours, and notes that he kept telling her to try
to help him, and noting that she didn't seem to be using her
left
arm and leg the way she should. Eventually he became concerned
about the lack of movement on that side, so decided to call the
ambulance. She was initially taken to an OSH, where she had a
NCHCT which showed a large (5x5x7cm) right temporal lobe
hemorrhage, at which time she was transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
- HTN (?) - husband is not aware of this diagnosis, but does
confirm that she has taken verapamil for several years.
- Depression/anxiety
Social History:
Lives with her husband in [**Name (NI) **]
Family History:
Family Hx: NC
Physical Exam:
Pt passed away.
No heart sounds, no breath sounds auscultated.
No palpable pulse
Pupils fixed an dilated, no corneal reflex
Pertinent Results:
[**2102-9-4**] 03:36AM GLUCOSE-164* UREA N-18 CREAT-0.6 SODIUM-139
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2102-9-4**] 03:36AM CK-MB-4 cTropnT-<0.01
[**2102-9-4**] 03:36AM WBC-11.8* RBC-4.04* HGB-13.1 HCT-37.2 MCV-92
MCH-32.4* MCHC-35.1* RDW-13.3
[**2102-9-4**] 03:36AM PLT COUNT-196
NCHCT
FINDINGS: Again noted is a large intraparenchymal hemorrhage
involving the
right parietal, frontal and temporal lobes. It measures 6.4 x
5.0 cm ,
previously 6.6 x 4.7 cm and is overall unchanged in size or
appearance. There
is persistent peri-hemorrhagic edema with stable effacement of
sulci and
ventricles. There is a 4-mm leftward shift from normally midline
structures
which is minimally decreased from prior. Stable intraventricular
hemorrhage
bilaterally and persistent hemorrhage into the supravermian
cistern is again
noted. The subarachnoid hemorrhage in the left occipital lobe is
unchanged
from prior study. The basal cisterns remain patent. No
hydrocephalus is
noted. An unchanged large CSF hypodensity in the anterior left
middle cranial
fossa is compatible with large arachnoid cyst. Prominent
anterior falcine
calcifications are present. There is no evidence of acute
fracture. The
visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION: Overall, no significant change in intraparenchymal
hemorrhage and
associated edema. Stable intraventricular hemorrhage bilaterally
with
persistent hemorrhage into supravermian cistern, unchanged from
prior study.
Brief Hospital Course:
ICU Course: Patient was admitted on [**2102-9-4**] for left-sided
weakness and headache and was found to have a large R temporal
hemorrhage. Exam findings on presentations were: the patient was
arousable to voice, oriented to self and [**Location (un) 86**], but thought it
was [**Location (un) 8599**]Hospital and was unsure of the date/year. She
had gross neglect of the left side, to self, visual stimuli and
to sensory stimuli. Eyes did not move past midline to the left,
and sensory input from left side of face was different as well
as decreased hearing on left v. neglect. L arm was extensor to
pain and left lower extremity had triple flexion to pain with
downgoing toes. Exam remained stable for 2 days in the ICU. MRI
imaging revealed no evidence of mass leading to likely etiology
of amyloid angiopathy. MRI showed early to late subacute blood
indicating that bleed may have started days prior to
presentation. Repeat CT on [**9-5**] showed no new blood and no
increase in midline shift. Blood pressure was stable and between
120-150 systolic on home dose of Verapamil.
On the neuro-floor the patietns blood pressure was not
controlled and verapamil was increased. The use of a second
theraputic [**Doctor Last Name 360**] was then used; norvasc 5mg qday. The patient
did have leukucytosis a CT chest with contrast was ordered which
did not demonstrate pulmonary embolism. A urinalysis was also
checked and was within normal range. The chest x-ray itself did
not show any infiltrate. A transthoracic echo was completed and
non concering for endocarditis or any overt pathology. The
patietns alertness was observed and found to wax and wane
significantly throughout the day. there was a repeat head CT
scan which did not show any diffrence in comparison to older
studies.
Over the weekend the patient decomensated and was found to be
more unresponsive. The patient was then made CMO-comfort
measures only. The patient passed away from repiratory
depression secondary to stroke on [**2102-10-14**] at 9:35 am. No autopsy
was completed or wanted by family.
Medications on Admission:
- Celexa 20mg
- Verapamil 240mg daily
- Omeprazole 20mg
- Klonapin 0.5mg
- Naproxen 500mg [**Hospital1 **]
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Death: Primary stroke
Secondary respiratory failure
Discharge Condition:
Death.
Discharge Instructions:
Death: n/a
Followup Instructions:
Death: N/A
Completed by:[**2102-9-14**]
ICD9 Codes: 431, 4019, 311, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4740
} | Medical Text: Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-25**]
Date of Birth: [**2101-5-5**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 80848**] is a 75yo woman with h/o dementia and CHF who comes in
from her nursing home after being found hypoxic.
Per her nursing home, she was short of breath all day with O2
sats of 86% on RA. She also complained of generalized weakness,
decreased po intake, and increased confusion per reports. Also
had tachypnea.
She initially presented to the [**Hospital 1562**] Hospital ED with VS BP
83/45, HR 97, RR 16, T 97.4, O2 Sat 91% on 2L. Her Hct was low
at 25 and she received 1 units of packed RBCs. She was guaiac
negative. CXR was felt to show LLL PNA as well as some heart
failure. Peripheral dopamine was started for a systolic blood
pressure in the 80s. She also received hydrocortisone 100mg IV
as well as levofloxacin, vancomycin, and imipenem for coverage
of health-care associated pneumonia in an ICU-level patient.
She also had hyperglycemia to the 400's and has no past h/o
diabetes.
Upon arrival at [**Hospital1 18**] ED, her initial VS were: 97.6 66/53
87 86% on ?L. She remained talkative and pleasant. CXR
demonstrated possible b/l consolidations. She was given 1500cc
of IV fluids and continued on a dopamine gtt. Her guardian was
[**Name (NI) 653**], and it was agreed that placement of a central line
would be consistent with her care. Therefore, a right IJ
catheter was placed and her pressors were transitioned to
levophed. Her code status was confirmed with her guardian as
DNR/DNI.
Upon arrival to the ICU, she wasn't sure, but she thought she
was short of breath. She denied headaches, chest pain, or
abdominal pain.
Past Medical History:
Dementia, alert and oriented x 1 at baseline
CHF, unknown EF
SIADH
Hypertension
COPD
Anemia
RBBB on ECG
h/o Right hip fracture
Social History:
Lives in nursing home. Prior heavy smoker.
Family History:
NC
Physical Exam:
VS: 97.1 121/90 111 25 85% on 15L face mask, but mask
not on
GENERAL: Pleasant, somewhat confused but interactive elderly
woman.
HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI.
Mucous membranes dry. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular tachycardia. Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**].
LUNGS: Crackles b/l up to about half way up the lung fields.
+Bronchial breath sounds at left base.
ABDOMEN: BS present. Obese but soft. There is a firm,
nontender subcutaneous nodule in the LUQ and what feels like
gas-filled bowel loops in the RUQ. No tenderness to palpation,
no distention.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis on left
and 1+ on right.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Alert, oriented to self only. Answers questions about
where she grew up appropriately. CN 2-12 intact. Preserved
sensation throughout. Strength is [**4-23**] in LUE and LLE. In RUE,
distal strength appears intact but she has 4+/5 proximal
strength. In RLE, she has difficulty raising her leg from the
bed or bending her knee from the bed but can bend her knee with
gravity. 2+ reflexes in UE that are equal BL, difficult to
elicit knee or ankle jerk b/l. Gait assessment deferred
Pertinent Results:
Admission Labs:
[**2176-11-21**] 01:00AM WBC-13.4* RBC-3.46* HGB-8.5* HCT-26.8*
MCV-77* MCH-24.6* MCHC-31.8 RDW-19.4*
[**2176-11-21**] 01:00AM PLT COUNT-374
[**2176-11-21**] 01:00AM NEUTS-92.8* LYMPHS-4.5* MONOS-1.7* EOS-0.8
BASOS-0.2
[**2176-11-21**] 01:00AM ALT(SGPT)-54* AST(SGOT)-147* LD(LDH)-596*
CK(CPK)-169* ALK PHOS-287* AMYLASE-15 TOT BILI-0.4
[**2176-11-21**] 01:00AM GLUCOSE-157* UREA N-45* CREAT-0.8 SODIUM-137
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2176-11-21**] 01:00AM LIPASE-25
[**2176-11-21**] 01:00AM cTropnT-<0.01
[**2176-11-21**] 01:00AM CK-MB-3
[**2176-11-21**] 01:00AM ALBUMIN-2.8*
[**2176-11-21**] 01:08AM LACTATE-1.5
Studies:
ECG [**2176-11-21**]
Sinus rhythm with first degree atrio-ventricular conduction
delay. Right
bundle-branch block. Diffuse non-diagnostic repolarization
abnormalities. No previous tracing available for comparison.
Echo [**2176-11-21**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%). There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: dilated, hypocontractile right ventricle without
evidence of major pulmonary hypertension (although pulmonary
artery pressure may have been underestimated), tricuspid
regurgitation, or pulmonic valve dysfunction
Chest Xray [**2176-11-21**]
Extensive left lung changes including interstial opacity,
effusion and hilar enlargement as well as right pulmonary edema.
Ongoing followup to resolution is recommended to exclude left
lung malignancy.
CTA Head/Neck [**2176-11-21**]
1. 7-mm aneurysm of the right M2 segment of the MCA. 3-mm
aneurysm of the 2 segment of the left MCA. No hemorrhage or
areas of significant vascular stenosis or occlusion.
2. Left pleural effusion and soft tissue density along the left
pulmonary artery, incompletely assessed.
CT Chest Abd Pelvis [**2176-11-21**]
1. Left hilar mass with upper lobe lymphangitic spread
concerning for a primary lung malignancy.
2. Left greater than right pleural effusions.
3. Numerous diffuse metastases within the liver and right
adrenal gland.
4. Left anterior abdominal wall subcutaneous metastasis
Abdominal ultrasound [**2176-11-21**]:
1. Diffusely infiltrated liver with innumerable nodules,
concerning for
diffuse metastatic disease. A CT is recommended for further
evaluation
2. Small perihepatic ascites, and as well as right pleural
effusion.
Brief Hospital Course:
75 year old woman with history of dementia and CHF who presented
with hypoxia, dyspnea, and septic shock and found to have
metastatic cancer. She expired on [**2176-11-25**] at 1:40pm.
# Hypoxic Respiratory Failure. She originally presented with
hypoxia and dyspnea, likely related to an underlying lung
malignancy. Her respiratory status continued to decline despite
high flow oxygen mask use and she ultimately went into hypoxic
respiratory arrest causing her death. She was DNR/DNI during
this stay.
# Septic Shock: She presented with hypotension requiring
pressors. She met SIRS criteria with leukocytosis > 12K, RR>20
and it was felt most likely to be a pulmonary source of
infection. She was started on Vancomycin and Meropenem, as well
as Levaquin for healthcare-associated pneumonia. She was later
found to have a left hilar lung mass that may have been
contributing to a post-obstructive pneumonia. She was given IV
fluids for resuscitation and maintained on Levophed for pressure
support.
# Metastatic Cancer: She was diagnosed with metastatic cancer
during this admission of unknown primary. She had subcutaneous
nodule on her abdomen and elevated liver enzymes and was found
to have a left hilar lung mass suspicious for a lung cancer
primary on CT scan. She was also found to have multiple
metastases to her liver.
# Congestive Heart Failure: She had some evidence of volume
overload on exam and chest xray but was not diuresed due to
likely septic shock. She had a TTE on admission that showed a
preserved EF but hypocontractile right ventricle with severe
pulmonary hypertension.
# Weakness on neurologic exam: She had right lower extremity
weakness that was felt to be due to her prior hip fracture.
# Anemia: On admission she had a hematocrit of 25 and was given
2 units PRBCs. Her hematocrit subsequently remained stable.
# Elevated INR: She had an INRo on admission that was felt to be
both nutritional and due to her substantial liver disease due to
metastases.
# Contacts: [**Name2 (NI) **] legal guardian until death was [**Name (NI) **] [**Name (NI) 84227**]
[**Telephone/Fax (1) 84228**] cell, [**Telephone/Fax (1) 84229**]. He was appointed by the court
since patient has mentally-ill daughter. [**Name (NI) **] daughter also
visited Ms. [**Known lastname 80848**] in the hospital and was present at the time of
her death.
Medications on Admission:
HCTZ 25mg po daily
Albuterol Sulfate 2.5 mg q2h prn
Vit D 1000 units po daily
Tums 500: 2 tabs po BID
Dulcolax 200mg po BID
MVI 1 tab po daily
Milk of Mag prn
Tylenol 650mg prn
Bisacodyl 10mg PR prn
Guaifenesin 10mg po q4h prn
Mag Ox 400mg po daily
Folic acid 1mg po daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Cancer
Hypoxemic Respiratory Arrest
Secondary Diagnosis:
Chronic diastolic heart failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 0389, 5119, 4280, 496, 4019, 2859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4741
} | Medical Text: Admission Date: [**2187-10-15**] Discharge Date: [**2187-11-19**]
Date of Birth: [**2122-4-29**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chief Complaint: back pain
Reason for MICU admission: Altered mental status and epidural
abscesses.
Major Surgical or Invasive Procedure:
EMG/NCS
.
lumbar puncture
.
[**2187-10-30**] Cervical and thoracic spinal abscess debridement
1. C7 corpectomy.
2. C5-C6 anterior cervical diskectomy and fusion with
application of interbody device.
3. Biopsy as well as culture of abscess - deep down to the
bone and spinal cord.
4. Application of interbody device, C7 expandable cage.
5. Application of [**Location (un) 976**]-[**Doctor Last Name 3012**] tongs with removal as well
as [**Location (un) 8766**] tongs with removal.
6. Posterior spinal decompression, C4 to T1.
7. Posterior spinal arthrodesis, C4 to T1.
8. Application of local autograft and allograft.
9. T3-T4 posterior decompression for abscess.
.
[**2187-11-2**] L5-S2 spinal abscess debridement
1. Iliac crest aspirate.
2. Iliac crest bone biopsy.
3. L5 bilateral laminectomy, medial facetectomy,
foraminotomy for removal of epidural abscess.
4. S1 bilateral laminectomy, medial facetectomy and
decompression for epidural abscess.
5. S2 decompression, bilateral laminectomy.
6. Repair of dural leak.
.
Percutaneous gastrojejunostomy tube placement
History of Present Illness:
65F with history of sciatica and chronic low back pain,
presenting to [**Hospital3 10310**] hospital with worsening back pain,
now admit to MICU with altered mental status, renal failure and
multiple epidural abcesses. She began to feel ill one week ago
when she acutely felt "awful" with low-grade fevers, back pain
and thought she had the flu. She went to the ED, where she was
treated with ibuprofen, Vicodin and Tamiflu. She stayed home
for the rest of the week resting her back, until the pain
worsened on Friday and she went to see her PCP. [**Name10 (NameIs) **] was
diagnosed with sciatica and sent home with Percocet. Over
Saturday and Sunday she became increasingly somnolent, sleeping
excessively and refusing to eat. Initially she would still
drink water through a straw, but stopped doing that Sunday. Her
husband called the [**Name (NI) **] for advice, and was told to call 911. She
had not complained specifically of headaches and he did not
notice photophobia or neck stiffness. She may have been
urinating less, but did not complain of dysuria.
EMS arrived to find her supine on the couch complaining of back
pain. In the OSH ED her VS were T 99.6, HR 120, BP 132/68, 91%
on RA. Given ceftriaxone, flagyl, clindamycin, and vancomycin.
Episode of transient tachycardia to 120s that resolved with
fluids. Found to have new ARF, a positive UA and leukocytosis
to 20K with 14% bands. No imaging done there before she was
transferred to the [**Hospital1 **].
.
In the [**Hospital1 18**] ED, initial vs were: T97.9 HR103 113/76 R30 98% on
RA. She was very somnolent and confused speech when awoken.
Noted to have pustular and petichial rash over torso and lower
extremities. Difficult neurologic exam given cooperation. Head
CT normal. MRI performed that was concerning for multiple
diffuse epidural collections on a noncontrast scan limited
somewhat by motion. Spine service was consulted, who reviewed
MRI and felt no spine compression - no surgical intervention
right now. Lactate elevated. She received vanco, ceftriaxone,
and was supposed to get ampicillin and acyclovir, which did not
happen prior to transfer. Did not LP given concern for epidural
collections. Blood cultures drawn (others pending at OSH) and
heme/onc consulted out of concern for TTP.
On the floor, she is somnolent but arousable and does open her
eyes. She grimaces on movement of any of her extremities but
does not speak. Will answer yes if asked if she has pain but
does not speak.
.
Review of systems:
(+) Per HPI, plus per husband a bad fall mechanical fall in her
garden two months ago causing a facial hematoma. Has had UTIs
in the past but non recently.
Past Medical History:
- back pain/sciatica
Social History:
Principal with multiple flu contacts. Denies EtOH, drinking,
illicit substances. Son lives in [**Location 10311**], [**State 8449**] and is
coming in tomorrow.
Family History:
Father lived to 96, mother lived to 86 then died after slow
decline.
Physical Exam:
ON ADMISSION:
Vitals: T: 97.7 BP: 107/52 P: 97 R: 26 O2: 93% on 4L NC
General: Arousable but closes eyes almost immediately. Does not
answer questions of orientation.
HEENT: PERRL, sclera anicteric, MMM, oropharynx with small
pustules and signs of buccal trauma from biting. Good dentition,
not signs of abscesses.
Neck: Neck stiff, but patient does not relax. No JVD. ? positive
Kernig's sign with resistance. Patient resisting too much for
Brudzinski's sign.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, grimaces on palpation of epigastrum and RUQ,
non-distended, bowel sounds present, no rebound tenderness, no
organomegaly
GU: foley in place.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffuse tiny pustules over erythematous base, generally
blanching, though some over hemorrhagic, non-blanching base.
More concentrated over thighs, sparing face, palms and soles.
.
ON DISCHARGE:
General: answers questions appropriately. speaks slowly.
fatigued. +anasarca
HEENT: PERRL, sclera anicteric
Neck: [**Location (un) 2848**] J in place
Lungs: tr crackles b/l bases
CV: tachcardic, no murmurs, rubs, gallops
Abdomen: soft, nontender, +BS
GU: foley in place.
Ext: warm, well perfused, severe pitting edema of b/l legs and
RUE
Skin: rash resolved
Neuro: CN2->12 grossly intact, able to move all fingers and
toes. able to flex L arm at elbow against gravity, but not
shoulder. not able to flex R arm against [**Last Name (un) 10312**] at arm or
shoulder. Cannot lift legs off bed. Sensation grossly intact.
Pertinent Results:
ON ADMISSION:
[**2187-10-15**]
.
136 98 133
------------- 196
4.5 13 5.7
.
Ca: 7.2 Mg: 3.1 P: 4.1
ALT: 168 AP: 153 Tbili: 3.6 Alb: 2.1
AST: 141 LDH: 513 Dbili: 3.1
Lip: 11
.
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
.
Hapto: 267
.
......12.3
10.9 ------ 58
......38.1
N:85 Band:0 L:2 M:13 E:0 Bas:0
.
PT: 13.4 PTT: 27.8 INR: 1.1
Fibrinogen: 837
.
Utox neg.
.
HIV neg
.
[**10-15**] MRI spine:
Multifocal small epidural collections as detailed above,
predominantly in the thoracic spine. No significant cord
compression is noted at any level.
Etiology for these collections could include infection or
hematomas.
Appearance is not suggestive of neoplasm, although correlation
with CSF
evaluation would be recommended.Evaluation is limited due to
lack of
contrast. Extensive degenerative changes in the lumbar spine
with clumping of nerve roots at L5-S1.
.
[**10-15**] CT head:
No acute intracranial process.
.
[**10-15**] CT abdomen/pelvis:
No evidence of hydronephrosis or obstructive renal calculi.
Given
noncontrast technique, pyelonephritis cannot be excluded.
Recommend clinical correlation.
.
[**10-16**] Echo:
No vegetations or clinically-significant regurgitant valvular
disease seen (reasonable-quality study). Normal global and
regional biventricular systolic function. Mild pulmonary
hypertension. In presence of high clinical suspicion, absence of
vegetations on transthoracic echocardiogram does not exclude
endocarditis.
.
[**10-17**] CXR:
Findings suggestive interval worsening of mild-to-moderate
pulmonary edema; chronic interstitial lung disease may be
present.
.
[**10-20**] MRI Spine:
Overall no significant change compared to the previous study
with
the exam limited by motion. Severe degenerative changes are
identified with foraminal narrowing as above. The previously
noted tiny epidural collection at L5-S1 level is not apparent
but mild epidural enhancement is seen. No definite new
collection is identified.
.
[**10-20**] MRI Head:
No significant abnormalities on MRI of the brain with and
without
gadolinium.
.
[**10-21**] CT Pelvis:
1) No evidence of right hip infection or abscess. Note that MRI
or
radionuclide bone scan are more sensitive for the detection of
early
infection.
2) Diffuse anasarca.
.
[**10-25**] EMG/NCS:
Complex, abnormal study. The electrophysiologic findings are
consistent with
a severe, subacute multilevel polyradiculopathy involving
cervical and
lumbosacral myotomes diffusely and would be consistent with
either an
inflammatory/infectious meningeal process. The abnormalities are
most
pronounced in the midcervical region. In addition, there is
evidence for a superimposed neuromyopathy, as may be seen in
acute quadriplegic myopathy of intensive care.
[**10-30**] C-Spine Non-Trauma:
Five intraoperative radiographs of cervical spine with final
images showing both anterior and posterior fusion extending from
C4 through T1 posteriorly and C5 through T1 anteriorly. There is
an interbody anterior graft at C5-6 and apparently C7 body has
been partially replaced by a metallic device.
.
[**10-31**] MRI Head:
1. No acute infarction or hemorrhage.
2. Sinus disease as described above, the activity of which is to
be
determined clinically.
3. Enhancing fluid within the left temporalis region suggestive
of phlegmon. This enhancing collection previously demonstrated
restricted diffusion. Additional subcutaneous scalp fluid
collections in the bilateral parietal regions may represent soft
tissue edema; however, there is no evidence of enhancement to
suggest abscess.
.
[**10-31**] MRI L Spine:
1. New posterior epidural abscess extending from the level of
L4-L5 to the
level of S2 with phlegmonous extension into the paravertebral
and paraspinous musculature. No evidence of enhancing
intervertebral discs to suggest discitis.
2. Advanced degenerative changes of the lumbar spine, unchanged
since the
previous examination.
.
[**11-1**] MRI T spine:
1. Epidural abscesses are identified at the upper thoracic spine
involving the levels of T1, T2, and T3, apparently slightly
smaller since the prior examination, however, there is
persistent enhancement surrounding the thecal sac and the spinal
cord.
2. No evidence of abnormal signal within the thoracic spinal
cord.
3. Epidural abscess is again demonstrated at the level of T7/T8,
causing
anterior thecal sac deformity and also demonstrating pattern of
enhancement.
4. Heterogeneous signal is again redemonstrated in the bone
marrow, likely
consistent with a combination of osteomyelitis/discitis.
5. Persistent bilateral pleural effusions.
.
[**11-2**] XR L-Spine:
Single intraoperative radiograph performed without a radiologist
present.
These demonstrate the lower lumbar spine. At the lumbosacral
junction,
instrumentation is demonstrated. Background degenerative change
is
demonstrated in the remainder of the lumbar spine in the single
intraoperative radiograph. For full details of surgery, please
consult the operative report.
.
[**11-9**] MRI SPINE:
IMPRESSION:
1. Persistent multiloculated small epidural abscess anterior to
the thecal
sac at the L5-S1 level measuring up to 2 cm in the SI dimension
and
compressimg the thecal sac at this level.
2. Markedly improved epidural abscesses at C5 through T1, T3-T4
and
posteriorly at L4-L5. Fluid collections in the resection bed
within the
cervical and lumbar spine may be postoperative, though infection
cannot be
excluded.
3. Persistent multifocal abnormal bone marrow signal
abnormality, consistent
with extensive osteomyelitis.
4. Large bilateral pleural effusions.
.
[**11-9**] right upper extremity ultrasound:
1. Fibrin sheath identified around PICC line in the right
basilic vein. The
fibrin sheath does not extend beyond the basilic vein.
2. No deep venous thrombosis identified in right upper limb.
.
[**11-12**] Ultrasound:
FINDINGS: Grayscale and color Doppler imaging of the common
femoral,
superficial femoral, and popliteal veins was performed
bilaterally. Normal
compressibility, flow, waveform, and augmentation demonstrated.
No
intraluminal thrombus is identified. Subcutaneous edema is noted
bilaterally.
IMPRESSION: No lower extremity deep venous thrombosis
bilaterally.
Brief Hospital Course:
#. MSSA infection (including epidural abscesses/vertebral
osteo/meningitis/bacteremia/skin lesions/UTI): Pt found to have
MSSA from blood and also grew MSSA from urine. Vancomycin was
started, then switched to Nafcillin when the organism was
identified. TTE was performed and showed no vegetations. It is
unknown what the portal of entry for the MSSA was. The
bacteremia, skin lesions and UTI resolved with appropriate
antibiotic therapy. Ortho spine was consulted and recommended
serial imaging to determine whether epidural abscesses were
increasing in size or causing spinal cord compression. Pt got
MRIs approximately once a week and on the 3rd it was more clear
that the patient would require surgery. She underwent
neurosurgery [**10-30**] and for epidural abscess drainage (and C7
corpectomy, C4-T1 fusion, T3-4 laminectomy). Multiple abscesses
present (~5, with 3 major ones), hardware place, cultures sent,
debrided. Upon repeat imaging post operatively, MRI showed
expanding T-spine epidural abscess, so she then underwent L
spine decompression [**11-2**] with debridement. Per ID, Gentamycin
was added to help with Nafcillin penetration for a 5-day course,
which was completed on [**11-6**]. Pt will continue on nafcillin for
at least 8 weeks and will follow up with spine and ID. Her
tentative stop date for nafcillin is [**2187-12-29**], or it may be
stopped on [**12-14**] when she visits ID. She has an appointment with
Spinal surgery on [**2186-12-27**]. she will need to have her staples
removed on [**2187-11-23**] in rehab with log role [**Last Name (LF) 10313**], [**First Name3 (LF) **] Spine
surgery. She is to have weekly [**First Name3 (LF) **] draws faxed to the Infectious
Disease Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
#Hospital Acquired Pneumonia: treated for HAP with vancomycin
and cefepime from [**11-11**] through [**11-18**]. Her nafcillin was
stopped during this treatment and was restarted on [**11-19**].
.
#. Altered mental status: The patient was initially minimally
responsive. This was thought to be secondary to meningitis as
well as the severity of her infection. This resolved
substantially with antibiotics. She did remain minimally
delerious throughout her stay (generally oriented x3 with
moments of confusion). MRI head was normal.
.
# Weakness: As pt's mental status improved and she became
cooperative with neuro exam, it became clear that she had
diffuse weakness with some focality (especially R arm) with
sensation relatively intact. Neurology was consulted who felt
that some of the weakness could be [**12-25**] cord inflammation and so
pt recieved pulsed steroids early in her admission without
significant effect. Pt underwent EMG which showed a mixed
picture (see EMG report for full details). Pt did undergo
decompression on [**10-30**] and [**11-2**] but strength remained similar.
.
#. GI Bleed: On [**2187-10-28**] pt developed melanotic stools and a
hematocrit drop from 24 to 20. IV PPI was continued and she
recieved 1U of prbcs and had an EGD which showed severe
ulcerations in stomach and duodenum most consistent with nsaid
use (pt did use ibuprofen at home). Per pt she had had a normal
colonoscopy at [**Hospital1 112**] 4 yrs ago and this was not repeated as an
inpt. Pt also reports h/o duodenal ulcers in the [**2147**]. An h
pylori was sent and was positive. Treatment of h pylori was
deferred in setting of nafcillin therapy and severe infection.
Pt was continued on PPI, eventually transitioned to PO. Pt will
need 2 week course of amoxicillin and clarithromycin after her
nafcillin treatment is complete (nafcillin does not cover h
pylori.)
She should continue lansoprazole until her visit with the
Gastroenterologist in [**Month (only) 404**].
.
#. Persistent Sinus Tachycardia: Pt maintained HR of ~100
throughout her admission (~1 month). This was felt to most
likely be related to her severe underlying infection and
recurrent low grade fevers. Intravascular volume depletion was
also a likely contributor given pt's low albumin and anasarca
and clinical appearance of being dry (dry mouth, low JVP). PE
was considered, however, pt was on DVT ppx throughout admission
and EKG did not have any changes. Further, pt's oxygen
requirement was minimal to none and ultimately it was decided
that PE was highly unlikely. Also given her prolonged stay may
be a PE, though this is less likely.
.
#. Edema: Patient was noted to have anasarca and an albumin of
1.9. Pt was not diuresed aggressively as she appeared
intravascularly depleted and had minimal oxygen requirement. Her
edema improved upon discharge.
.
#. Anemia: Pt remained anemic throughout her stay. Perhaps she
has had ulcers for some time contributing to her anemia. Her
reticulocyte count was 6.7 arguing against marrow suppression as
the etiology, however, iron studies were consistent with anemia
of chronic disease. The transfusion goal was set at 22. She
recieved 2U of PRBCs throughout her stay.
.
#. Pain: Patient had severe back pain throughout her admission
that was ultimately treated with a fentanyl patch with small
boluses of IV morphine for breakthrough pain. A kanair bed was
also found to help with her pain.
.
#. Rash: On admission pt had 2 rashes. She had diffuse small
pustules which grew MSSA and resolved c antibiotics. She also
had, on the left back, a 4 x 3cm erythematous plaque with a
central brown / black, rough, necrotic area which was biopsied
by dermatology and showed "Focal necrotizing vasculitis in
mid-dermis with focal thrombosis, and ischemic necrosis of
epidermis and appendages" which dermatology felt was consistent
with a reactive process, rather than representing a primary
vasculitis, given the clinical scenerio.
.
#. Acute renal failure: Pt had [**Last Name (un) **] on admission, which resolved
c IVF.
.
#. Elevated transaminases: Pt had elevated LFTs on admission,
most likely from poor perfusion in the setting of dehydration or
billiary sludging in the setting of SIRS. RUQ ultrasound
unremarkable. This was trended and resolved.
.
#. Thrombocytopenia: in combination with direct bilirubinemia
was concerning for consumptive process like TTP or DIC on
admission, however no chistocytes on smear. Most likely due to
poor production in the setting of infection and resolved during
admission.
.
#. Nutrition: she failed speech and swallow on [**11-12**]. A
percutaneous gastrojejunostomy tube was placed on [**11-15**] and tube
feeds continued.
.
# Electrolyte Abnormalities: Patient had persistent hypokalemia
and hypophosphatemia. Standing electrolyte orders were instilled
and should be continued in rehab until levels normalize. Also, a
Chem-10 should be checked every other day while taking these
medications.
#. Access: Patient has a PICC placed in the right arm on
[**2187-10-19**].
#. Code: Full Code
-------------
TO DO
- treat for h pylori after treatment for MSSA complete
- take out staples on [**2187-11-23**] in rehab
- continue age appropriate cancer screening
- continue pain management without nsaids
Medications on Admission:
Tylenol and ibuprofen generally for back pain. This past week
Tamiflu, Vicodin and Percocet.
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution [**Date Range **]: One (1) PO Q6H (every 6
hours) as needed for pain.
2. Miconazole Nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical TID
(3 times a day).
3. Heparin, Porcine (PF) 10 unit/mL Syringe [**Date Range **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
4. Lovenox 40 mg/0.4 mL Syringe [**Date Range **]: One (1) Subcutaneous once
a day: to be discontinued when able to move around q8h. .
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Date Range **]:
[**11-24**] Adhesive Patch, Medicateds Topical DAILY (Daily): 12 hours
on, 12 hours off .
6. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: per sliding
scale Injection ASDIR (AS DIRECTED) as needed for
hyperglycemia.
7. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
8. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constip.
9. Polyethylene Glycol 3350 17 gram/dose Powder [**Month/Day (2) **]: One (1) PO
DAILY (Daily) as needed for constipation.
10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day): Hold for loose stools.
11. Morphine 2 mg/mL Syringe [**Month/Day (2) **]: One (1) Injection Q4H (every
4 hours) as needed for pain: hold for sedation, rr<12.
12. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Lisinopril 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
15. Outpatient [**Name (NI) **] Work
PT, PTT, INR, Chem-7, LFTs, CBC/Diff every monday
faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]
16. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Telephone/Fax (1) **]: Two (2)
grams Intravenous Q4H (every 4 hours): Start Date: [**2187-11-19**]
Last Dose should be [**2187-12-28**].
17. Outpatient [**Month/Day/Year **] Work
Please check chem-10 every other day until electrolytes are
normalized.
18. Potassium Chloride 20 mEq Packet [**Month/Day/Year **]: One (1) packet PO TID
(3 times a day): hold for K > 4.
19. Phos-NaK 280-160-250 mg Powder in Packet [**Month/Day/Year **]: Two (2) PO
once a day: hold for Phos > 4.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
MSSA epidural abscesses, MSSA meningitis and vertebral
osteomyelitis and discitis, MSSA UTI, MSSA bacteremia, MSSA
diffuse skin pustules, profound weakness. dysphagia. anasarca.
duodenal and gastric ulcers complicated by bleeding.
Discharge Condition:
Vital signs stable. very weak legs and R arm more swollen than L
arm, but very diffuse weakness. anasarca. intermittently
confused.
Discharge Instructions:
You were admitted with a bacterial infection of your spinal
fluid and the bones of your spine as well as your urine and
blood and skin. You were treated with antibiotics and the
orthopedic surgeons did two surgeries to take out the abscesses.
You also had a lot of weakness, for which we had neurology see
you. They felt that your weakness was due to a combination of
factors including the infection around your spine and also some
muscle weakness from being so weak. You worked extensively with
physical therapy and will continue to do so at rehab.
.
You were having difficulty swallowing as well, thought secondary
to pharyngeal inflammation from your cervical spine surgery and
muscle weakness from prolonged hospitalization. You therefore
had a gastrojejunostomy tube placed to receive nutrition.
.
You will need to wear the cervical collar until you meet with
the spine surgeons on [**2187-12-27**]. You have staples on
your back. These will need to be removed [**2187-11-23**]. We spoke with
the spine surgeons and they stated your facility can remove
these under log role precautions.
.
You will need to continue nafcillin until at least [**2187-12-28**],
unless the Infectious Disease specialists tell you otherwise at
your appointment on [**2187-12-14**].
Followup Instructions:
Please help Ms [**Known lastname 166**] go to the following appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (infectious disease), MD. Phone
[**Telephone/Fax (1) 457**] Date: [**2187-11-28**] 10:30am
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (infectious disease), MD
Phone:[**Telephone/Fax (1) 457**] Date/Time: [**2187-12-14**] 9:30a
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 10314**] (gastroenterology), MD
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2187-12-5**] 3:00p
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (spine surgery) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2187-12-27**] 12:20
ICD9 Codes: 5845, 5185, 5070, 2760, 7907, 5990, 2762, 2875, 2851, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4742
} | Medical Text: Admission Date: [**2183-9-29**] Discharge Date: [**2183-10-3**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
81 year-old female with history of MDS, GI bleeding,
thrombocytopenia, and anemia presents with BRBPR. Pt. was
discharged from [**Hospital1 18**] one week ago for bleeding that wsa managed
with embolization of the gastroduodenal artery (bled from
hemorrhoids, avms, tics and ulcers!). For the past week, the
patient has been at rehab and was doing relatively well until
this AM when, after having a bowel movement, passed
approximately 200 cc of bright red blood.
Was found to be in ARF (Cr 5; bicarb 8); s/p MI (CK flat, Tr 7;
inf TWI); plts in 20's on admission.
Was initially transferred to MICU; managed supportively; now
called out.
Past Medical History:
1) CAD s/p 3 vessel CABG
2) CHF
3) Osteoarthritis
4) High cholesterol
5) Hypothyroidism
6) HTN
7) Heart murmurs since age 10, when she was diagnosed with
scarlet fever and diptheria. She reports some neck surgery
around the time of this diagnosis.
8) MDS, diagnosed in [**5-18**]. Bone marrow biopsy was consistent
with MDS and refractory anemia with excess blasts. The bone
marrow showed 11% blasts.
9) Hemorrhoidal and diverticular bleeding, diagnosed when the
patient was admitted to a hospital in [**Location (un) **] in [**3-19**].
Social History:
The patient has an 80-pack year smoking history. She quit in
[**2162**]. She currently does not drink alcohol, but she was a social
drinker in the past. Her husband died of [**Name (NI) 2481**] disease.
She is a retired social worker. She recently moved from
[**Location (un) 19061**] to [**Location (un) 86**] so that she may be with her family.
Family History:
No family history of cancer. Her mother died at age [**Age over 90 **] of a MI.
Physical Exam:
98 112/20 45 20 97%ra
pleasant F in nad
perrla; unecteric; mmm; no mucosal bleeding
cta B
rrr; s1/s2; 2/6 sem radiating to carotids
abd: soft; nt/nd; positive bs
ext: 2+ edema
Pertinent Results:
[**2183-9-29**] 09:35AM PT-13.4 PTT-22.2 INR(PT)-1.1
[**2183-9-29**] 09:35AM PLT SMR-VERY LOW PLT COUNT-24* LPLT-3+
[**2183-9-29**] 09:35AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+
ELLIPTOCY-1+
[**2183-9-29**] 09:35AM NEUTS-54 BANDS-12* LYMPHS-18 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-7* NUC RBCS-2*
[**2183-9-29**] 09:35AM WBC-11.6*# RBC-3.33* HGB-10.0* HCT-29.8*
MCV-90 MCH-29.9 MCHC-33.5 RDW-19.0*
[**2183-9-29**] 09:35AM CALCIUM-7.6* PHOSPHATE-6.7*# MAGNESIUM-2.3
[**2183-9-29**] 09:35AM GLUCOSE-97 UREA N-92* CREAT-5.0*# SODIUM-130*
POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-9* ANION GAP-23*
[**2183-9-29**] 11:30AM C3-63* C4-36
[**2183-9-29**] 11:30AM ALBUMIN-2.7* CALCIUM-7.7* PHOSPHATE-6.2*
MAGNESIUM-2.3
[**2183-9-29**] 11:30AM CK-MB-8 cTropnT-7.24*
[**2183-9-29**] 11:30AM CK(CPK)-278*
[**2183-9-29**] 11:30AM GLUCOSE-93 UREA N-95* CREAT-5.0* SODIUM-132*
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-9* ANION GAP-24*
Brief Hospital Course:
1. GIB: resolved with supportive measures. Likley hemorrhoidal
bleed as opposed to upper gi source. required several units of
packed red cells. no recurrent bleeding. can only get hla
matched platelets! tolerating regualr diet
2. MDS: refractory thrombocytopenia. Has requited HLA matched
plts in combo with IVIG on past admission. Here responded to HLA
matched plt transfusion. Hct stable (was transfused). Amicar was
initially held due to renal failure; restarted at low dose. Dose
needs to be slowly increased back to outpatient dose ogf 4 mg po
q6H as Cr improves (may increase to 2 g po q6h if Cr<2
tomorrow). danazol restrted today. We are tapering prednisone
(has been on it for 2 weeks in hope to "stabilize"
thrombocytopenia, but did not help. Needs to continue prednisone
taper
3. s/p MI: Tr 7 on admission in association with inferior T wave
inversions and new inf apical wall HK on echo (preserved EF).
could not get asa or heparin due to severe thrombocytopenia. Tr
trending down. no sxs of ischemia/ht dz. started low dose b-bl.
PT ok.
4. ARF: non-oliguric. likely combo or prerenal--> atn and
atheroembolic dz (C3 low; has eosinophils in urine). has been
getting iv bicarb since bicarb of 9 on admission; started on
bicitra; bicarb improving; Cr improving (2.1 today)
5. ID: had unexplained bandemia. was empirically on ceftriaxone.
Then developed leukocytosis, diarhea and spiked to 101; started
on IV Flagyl for C. Diff (C. diff toxin P). IV rather than po
since not sure how much absorbing po
6. fen: cardiac diet; protonix; pneumoboots
7. FULL code: agrees to be intubated for 2 days if needed8. h/o
H. Pylori; pt was treated with h. pylori with PPI;
clarithromycin and amox. abxs were stopped when pt developed
diarrhea. she completeled close to 10 days of H/pylori therepy
and we thought that risks of continuing abxs in light of C. diff
outweighed the benefits
Medications on Admission:
levoxyl
norvasc 10 mg q am; 5 mg q pm
losartan 100 mg po qd
terazosin 2 mg qhs
Zocor 40 mg po qd
clonidine 0.1 [**Male First Name (un) 239**]
amicar 4 mg po q6h
protonix
lopressor 50 mg po bid
caltrate 600 mg po qd
prednisone 80 mg po qd
danazol 400 mg po bid
clarithromycin
amoxicilline
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
3. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID (3 times a day).
8. Aminocaproic Acid 500 mg Tablet Sig: Two (2) Tablet PO Q 6H
().
9. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Fifteen (15) ML PO BID (2 times a day).
10. Danazol 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 14 days.
14. Cholestyramine 4 g Packet Sig: One (1) PO BID (2 times a
day).
15. prednisone
10 mg dispense #28
taper:
40 mg po qd x 2 days
30 mg po qd x 3 days
20 mg po qd x 3 days
10 mg po qd x 3 days
5 mg po qd x 3 days and stop
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. GIB
2. MI
3. A/CRF
4. MDS with refractory thrombocytopenia
Discharge Condition:
stable
Discharge Instructions:
1. please take all you medications as directed
2. if develop bleeding, please call your hematologist and your
pcp and be evaluated in emergency room
Followup Instructions:
Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2183-10-21**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-10-21**] 9:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2183-11-6**] 8:20
please see your pcp within next 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2183-10-3**]
ICD9 Codes: 5849, 5789, 2875, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4743
} | Medical Text: Admission Date: [**2104-9-24**] Discharge Date: [**2104-10-1**]
Date of Birth: [**2037-3-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 5062**]
Chief Complaint:
shortness of breath, increasing oxygen requirement
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 y/o female with metastatic breast ca (mets to liver, lung,
and possibly cavernus sinus) on ongoing weekly paclitaxel,
presented with persistent fevers. On [**2104-9-16**] patient began her
cycle 2 day 1 of paclitaxel. On that day she was found to have a
fever of 100.9. Her only symptom was generalized achiness. At
that time CXR was negative, as were blood cultures. Her
urinalysis showed 6 WBCs and few bacteria. She was treated
empirically with ciprofloxacin for a possible UTI x 1 week.
.
Fevers continued with development of URI symptoms, myalgias,
non-productive cough. She was admitted to [**Hospital1 18**] on [**9-24**]. CXR on
[**9-24**] showed no acute cardiopulmonary process. CXR on [**9-25**]
showed mild asymmetry in the upper zones with some suggested
increased opacification on the right.
.
Of note, her WBC has trended down to 1.6 in setting of recent
chemotherapy and reaching nadir. Vancomycin, Cefepime, and
Azithromycin were started on [**2104-9-25**].
.
On the floor, patient triggered twice for increased respiratory
rate into the high 20s and low 30s. Her oxygen requirement has
risen from 98% on 2L NC to 88-90% on [**4-17**] L NC overnight. Her ABG
was 7.43/40/62 on 5L NC. CTA is read as atypical infiltrate
versus diffuse lymphangitic carcinomatosis resulting in
congestion of the lung parenchyma. Oseltamivir 75 mg PO/NG [**Hospital1 **]
was added on [**9-26**], ID was consulted, and ICU admission was
requested for increasing oxygen requirement and request for
bronchoscopy with biopsy - question is whether this pulmonary
process is indeed lymphomatous spread or simply atypical
infection.
.
Of note, patient has been on intermittent decadron doses since
cyperknife treatment (last dose 5 days ago).
.
Prior to transfer, patient was hemodynamically stable. O2
reported as 80% on 4L NC and 90% on 6L NC.
.
On arrival to the ICU the patient reported that she was working
somewhat more than usual to breath. She denied pain anywhere or
any other complaints.
Past Medical History:
# Metastatic breast cancer:
- [**2098**]: a mass was found in her left breast on mammogram
- [**2099-4-23**]: lumpectomy. Pathology showed invasive ductal
carcinoma, ER positive but Her2 negative.
- [**Date range (1) 104395**]: received chest irradiation followed by
adjuvant endocrine therapy on protocol MA27 with exemestine.
She continued on exemestine until [**2102-3-17**] when a chest X-ray
showed a 4 mm mass in her left lung and biopsy by Dr. [**First Name (STitle) **]
[**Doctor Last Name **] showed metastatic breast carcinoma.
- [**Date range (2) 104396**]: received capecitabine
- [**8-/2103**]: chemotherapy was switched to liposomal doxorubicin
because of progressive lung metastases. She continued on
liposomal doxorubicin until she again had progressive disease
and was started on paclitaxel.
- [**2104-8-5**]: PET showed FDG-avid disease in her lungs and possbily
the liver.
- early [**2104-7-13**]: she experienced increased, but mild, headache
frequency. She experienced blurry vision in OS that lasted for
seconds upon awakening in a.m. MRI showed Meckel's cave
enhancing mass. This was felt to be possible brain met vs.
unresectable meningioma. She was treated with CyberKnife which
she completed on [**2104-8-29**]. She was on dexamethasone during her
cyberknife treatments.
.
OTHER MEDICAL HISTORY:
Hypertension
Hypercholesterolemia
TAH-BSO for fibroids.
Social History:
Retired. Smoked less than 1 pack of cigarettes per day for 10
years before quitting in [**2077**]. Zero to 3 alcoholic drinks per
week. No illicit drugs
Family History:
Her mother has hypertension and hypercholesterolemia. Her father
died at age 81 from pancreatic cancer. Brothers have
hypertension and hypercholesterolemia. Daughter had [**Name2 (NI) 500**]
allograft after resection of a right radius giant cell tumor.
Physical Exam:
GEN: Alert in NAD
HEENT: EOMI, PERRL, neck supple, MMM, no thrush/exudate
LUNG: Fine right sided crackles, no wheezes or rhonchi
CV: RRR, S1+S2, no M/R/G
ABD: +BS, NT/ND
EXT: no edema, no rash, 2+ pedal pulses
NEURO: CN II-XII without focal deficit
Pertinent Results:
Hematology
[**2104-9-30**] 06:20AM BLOOD WBC-5.7 RBC-2.70* Hgb-9.1* Hct-26.6*
MCV-98 MCH-33.7* MCHC-34.3 RDW-17.2* Plt Ct-179
[**2104-9-29**] 06:00AM BLOOD WBC-5.0 RBC-2.16* Hgb-7.5* Hct-22.3*
MCV-103* MCH-34.4* MCHC-33.4 RDW-16.0* Plt Ct-172
[**2104-9-28**] 05:55AM BLOOD WBC-3.4*# RBC-2.17* Hgb-7.4* Hct-22.0*
MCV-101* MCH-34.1* MCHC-33.7 RDW-15.2 Plt Ct-147*
[**2104-9-27**] 03:24AM BLOOD WBC-1.7* RBC-2.30* Hgb-8.2* Hct-23.1*
MCV-101* MCH-35.7* MCHC-35.5* RDW-15.9* Plt Ct-141*
[**2104-9-26**] 06:40AM BLOOD WBC-1.6* RBC-2.38* Hgb-8.3* Hct-24.0*
MCV-101* MCH-34.9* MCHC-34.6 RDW-14.9 Plt Ct-132*
[**2104-9-25**] 09:00PM BLOOD WBC-1.8* RBC-2.54* Hgb-8.8* Hct-25.4*
MCV-100* MCH-34.5* MCHC-34.4 RDW-15.2 Plt Ct-161#
[**2104-9-25**] 06:05AM BLOOD WBC-1.4* RBC-2.31* Hgb-8.1* Hct-23.1*
MCV-100* MCH-34.9* MCHC-34.9 RDW-15.1 Plt Ct-106*
[**2104-9-24**] 06:00PM BLOOD WBC-1.6* RBC-2.49* Hgb-9.1* Hct-25.1*
MCV-101* MCH-36.4* MCHC-36.1* RDW-16.6* Plt Ct-146*
[**2104-9-24**] 12:15PM BLOOD WBC-2.3* RBC-2.78* Hgb-9.7* Hct-27.2*
MCV-98 MCH-35.0* MCHC-35.8* RDW-14.8 Plt Ct-169
[**2104-9-29**] 06:00AM BLOOD Neuts-79.7* Lymphs-13.1* Monos-6.8 Eos-0
Baso-0.3
[**2104-9-26**] 06:40AM BLOOD Neuts-60 Bands-6* Lymphs-26 Monos-6 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2*
[**2104-9-29**] 06:00AM BLOOD PT-13.7* PTT-27.8 INR(PT)-1.2*
[**2104-9-28**] 05:55AM BLOOD PT-13.6* PTT-23.7 INR(PT)-1.2*
[**2104-9-28**] 05:55AM BLOOD Gran Ct-2830
[**2104-9-27**] 03:24AM BLOOD Gran Ct-1450*
[**2104-9-25**] 06:05AM BLOOD Gran Ct-1000*
[**2104-9-24**] 12:15PM BLOOD Gran Ct-1730*
Chemistries:
[**2104-9-30**] 06:20AM BLOOD Glucose-112* UreaN-21* Creat-0.9 Na-136
K-5.2* Cl-103 HCO3-25 AnGap-13
[**2104-9-30**] 10:55AM BLOOD Na-135 K-4.8 Cl-101
[**2104-9-29**] 06:00AM BLOOD Glucose-124* UreaN-18 Creat-0.8 Na-138
K-4.6 Cl-106 HCO3-22 AnGap-15
[**2104-9-28**] 05:55AM BLOOD Glucose-184* UreaN-15 Creat-0.6 Na-137
K-4.0 Cl-105 HCO3-22 AnGap-14
[**2104-9-27**] 03:24AM BLOOD Glucose-193* UreaN-13 Creat-0.6 Na-137
K-3.8 Cl-105 HCO3-24 AnGap-12
[**2104-9-26**] 06:40AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-136
K-3.4 Cl-102 HCO3-27 AnGap-10
[**2104-9-25**] 06:05AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-137
K-4.0 Cl-103 HCO3-26 AnGap-12
[**2104-9-29**] 06:00AM BLOOD ALT-82* AST-44* LD(LDH)-571* AlkPhos-55
TotBili-0.4
[**2104-9-28**] 05:55AM BLOOD ALT-85* AST-61* LD(LDH)-602* AlkPhos-54
TotBili-0.4
[**2104-9-27**] 03:24AM BLOOD ALT-84* AST-77* LD(LDH)-625* AlkPhos-59
TotBili-0.4
[**2104-9-26**] 06:40AM BLOOD ALT-61* AST-59* LD(LDH)-521* AlkPhos-53
TotBili-0.6
[**2104-9-25**] 09:00PM BLOOD ALT-67* AST-69* LD(LDH)-570* AlkPhos-62
TotBili-0.6
[**2104-9-30**] 06:20AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.4
[**2104-9-29**] 06:00AM BLOOD Albumin-3.0* Calcium-8.3* Phos-3.5 Mg-2.4
[**2104-9-28**] 05:55AM BLOOD Albumin-3.0* Calcium-8.0* Phos-2.9 Mg-2.2
[**2104-9-27**] 03:24AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.1
[**2104-9-26**] 06:40AM BLOOD Albumin-2.9* Calcium-7.9* Phos-2.6*
Mg-2.0
[**2104-9-25**] 09:00PM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.0*
Mg-2.0
[**2104-9-25**] 06:05AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
[**2104-9-27**] 09:41AM BLOOD VitB12-GREATER TH Folate-15.2
[**2104-9-24**] 01:40PM BLOOD CEA-7.9*
[**2104-10-1**] 05:42PM BLOOD Vanco-18.3
[**2104-9-27**] 07:54AM BLOOD Vanco-8.0*
[**2104-9-26**] 09:08AM BLOOD Type-ART Tidal V-5 FiO2-100 pO2-62*
pCO2-40 pH-7.43 calTCO2-27 Base XS-1 AADO2-628 REQ O2-100
Micro:
Bcx [**9-24**], [**9-25**], [**9-26**], [**9-27**]: Neg
Ucx [**9-24**], [**9-26**]: Coag+ staph (MRSA)
Ucx [**9-27**]: Neg
Legionella Ag: Neg
Crypto Ag: Neg
Vaginal Swab: neg for yeast
CMV viral load: neg
Induced sputum [**9-27**]: 1+ organisms c/w OP flora, Res Cx: PND,
PCP: [**Name10 (NameIs) 104397**]
ANC: 2830
Galactomanin/Beta Glucan: neg
Imaging:
ECHO [**2104-9-29**]
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Doppler parameters are indeterminate for left ventricular
diastolic function. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. No
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Indeterminate diastolic indices. No endocarditis,
abscess or significant valvular regurgitation seen
CTA [**9-26**]:
1. No pulmonary embolus or acute aortic abnormality.
2. Diffuse lymphangitic carcinomatosis, with resulting
widespread ground-glass opacities indicating parenchymal
congestion (reflecting non-cardiogenic edema).
3. Grossly unchanged innumerable pulmonary nodules compatible
with
metastases.
CXR [**9-24**]: IMPRESSION: No evidence of pulmonary abnormalities to
suggest the cause of the patient's ongoing fever. No acute
cardiopulmonary process.
CXR [**9-25**]: FINDINGS: In comparison with the study of [**9-24**],
there is little overall change. There is, however, mild
asymmetry in the upper zones with some suggested increased
opacification on the right. This could conceivably be a
developing area of consolidation. Mild indistinctness of
pulmonary vessels raises the possibility of mild elevation in
pulmonary venous pressure.
Brief Hospital Course:
# Hypoxia ?????? On admission, patient had oxygen saturations in
mid-90s on 6L NC. CT showed diffuse lymphangitic carcinomatosis
resulting in congestion of the lung parenchyma which was thought
to the be the cause of her hypoxia. Infectious etiology was
considered and she was treated with bactrim 2DS Q8H for empiric
PCP treatment, azithromycin [**Name Initial (PRE) **] 5 days and prednisone. She was
also intitially treated with cefepime for broad coverage, which
was stopped once she improved clinically. By discharge, she no
longer required with oxygen supplementation.
# UTI: [**Month (only) 116**] have been the source of her fevers. Two urine
cultures grew Staph aureus. She was treated with iv vancomycin,
which will be continued as outpatient via picc line. Echo was
done and was negative for cardiac vegetation.
# Metastatic breast cancer: most recent paclitaxel dose was on
[**2104-9-16**]. CEA elevated at 7.9 up from 4.9 last month. Further
treatment per outpatient oncology.
# Elevated LFTs - Elevated on admission. Were normal 1 month
prior when last checked. [**Month (only) 116**] have been secondary to liver
metastases vs. infectious process vs secondary to steroids. CMV
was negative.
# Hypertension: Stable. Continued on atenolol 50 mg daily and
lisinopril 5 mg daily.
# GERD: continued on PPI.
# Hypothyroidism: continued on levothyroxine 75 mcg daily.
# Hyperlipidemia: continued on simvastatin 20 mg daily.
Medications on Admission:
atenolol 50 mg daily
chlorhexidine mouthwash
ciprofloxacin 500 mg [**Hospital1 **]
esomeprazole 40 mg [**Hospital1 **]
ibandronate 150 mg monthly
levothyroxine 75 mcg daily
lisinopril 5 mg daily
lorazepam 0.5-1 mg q6h prn nausea, insomnia
simvastatin 20 mg daily
aspirin 81 mg daily
calcium-vitamin D3 630 mg-400 units daily
cholecalciferol 1000 units daily
MVI
omega-3 fatty acids
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 10 days: STOP [**2104-10-11**].
Disp:*20 Recon Soln(s)* Refills:*0*
3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
4. ibandronate Oral
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for nausea, anxiety.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. multivitamin Oral
11. omega-3 fatty acids Oral
12. chlorhexidine gluconate 0.12 % Mouthwash Mucous membrane
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. prednisone 20 mg Tablet Sig: see below Tablet PO see below
for 17 days: Take 2 tabs twice a day until [**10-2**] for 1.5 days.
Starting [**10-3**] take 2 tabs once a day for 5 days. Then starting
[**10-8**] take 1 tab once a day for 11 days (stop [**2104-10-18**]).
Disp:*27 Tablet(s)* Refills:*0*
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO Q 8H (Every 8 Hours) for 18 days: until [**2104-10-18**].
Disp:*108 Tablet(s)* Refills:*0*
17. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 7 days: (stop [**10-5**]).
18. Calcium 600 + D(3) Oral
19. cholecalciferol (vitamin D3) Oral
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary: lymphangetic carinomatosis, urinary tract infection
Secondary: Metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 7747**],
It was a pleasure taking part in your care. You were admitted to
the hospital with persistent fevers. You were found to have a
urinary tract infection. You were treated with intravenous
antibiotics. You will continue to take antibiotics after
discharge. The instructions are:
-Vancomycin 1250 mg iv infusion twice a day until [**2104-10-11**]
You also had difficulty breathing. This was thought to be caused
by an infection. You improved with steroids and antibiotics. We
got a repeat CT scan which showed that you had spread of your
cancer in your lungs. This may have contributed to your
shortness of breath.
The following changes were made to your medications:
-STARTED Vancomycin 1250 mg intravenous twice a day until
[**2104-10-11**]
-STARTED Bactrim DS 2 tabs every 8 hours until [**2104-10-18**]. After
you finish this prescroption you will need to be on Bactrim for
prophylaxis for PCP.
[**Name10 (NameIs) **] Prednisone taper- until [**2104-10-18**]
-STARTED Miconazole vaginal cream- until [**2104-10-4**]
-STARTED Senna 1 tab twice a day as needed for constipation
-STARTED Colace twice a day to prevent constipation
Followup Instructions:
You may need to follow-up with the infectious disease clinic.
The number to call is: ([**Telephone/Fax (1) 4170**].
Please keep the following appointments:
Department: RADIOLOGY
When: MONDAY [**2104-10-6**] at 9:55 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2104-10-6**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2104-10-14**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], NP [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4744
} | Medical Text: Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-13**]
Date of Birth: [**2054-8-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Acute Paralysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yo Korean gentleman awoke this morning, talked to the bathroom
and felt sudden onset back and abdominal pain after which he
lost functioning of bilateral lower extremeties. Taken to OSH
where abdominal CT scan thought to show dissection of thoracic
AAA, Pt xferred to [**Hospital1 18**] for possible surgical
intervention but on review of outside CT, no aneurismal rupture
noted.
Past Medical History:
GERD
HTN
Social History:
Previously heavy smoker, quit 1.5 yrs ago.
no alcohol
Family History:
non contributary
Physical Exam:
VS: afeb 130/60 72
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: Soft/distended
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
MS: A&O x 3, interactive, appropriate, following all commands
Speech fluent w/o paraphasic errors, +naming of wholes & parts,
+repetition, +comprehension
No evidence of neglect with visual or tactile stimulation
No apraxia: able to comb hair, screw in light bulb
CN: I - not tested, II,III - PERRL, VFF by confrontation, optic
discs sharp, visual acuity OD, OS; III,IV,VI - EOMI, no ptosis,
no nystagmus; V- sensation intact to LT/PP, responds to nasal
tickle, masseters strong symmetrically; VII - no facial
weakness/asymmetry; VIII - hears finger rub B; IX,X - voice
normal, palate elevates symmetrically, gag intact; [**Doctor First Name 81**] -
SCM/Trapezii [**6-2**] B; XII - tongue protrudes midline, no atrophy
or
fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia. No
pronatordrift. No asterixis.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
C5 C5-6 C7 C6-7 C7 C8 T1 C8-T1
L 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 0 0 mute
R 2 2 2 0 0 mute
Sensory: LT intact throughout; temperature, vibration, pin
decreased from T10 level down.
Coord: FNF intact.
Gait: unable to perform.
Pertinent Results:
[**2130-4-13**]
WBC-7.4 RBC-4.79 Hgb-15.2 Hct-44.7 MCV-93 MCH-31.7 MCHC-34.0
RDW-13.7 Plt Ct-103*
[**2130-4-12**]
PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2130-4-13**]
Glucose-139* UreaN-46* Creat-1.1 Na-139 K-4.3 Cl-107 HCO3-24
AnGap-12
[**2130-4-10**]
ALT-62* AST-20 CK(CPK)-95 AlkPhos-62 TotBili-2.1*
[**2130-4-12**]
Calcium-8.1* Phos-3.2 Mg-2.3
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
URINE RBC-[**4-2**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2
URINE Hours-RANDOM Creat-43 Na-LESS THAN TotProt-13
Prot/Cr-0.3*
[**2130-4-10**] 11:13 AM
RENAL U.S. PORT
TECHNIQUE: Portable renal ultrasound with Doppler studies.
FINDINGS: The right kidney measures 10.9 cm in length, the left
11.6 cm. Within the upper pole of the right kidney, two simple
cysts, each measuring 2.7 cm in diameter, are visualized, as
well as a 2.1 cm simple cyst in the lower pole of the left
kidney. These correspond to a hypoattenuating foci seen on the
recent CT. In the lateral mid pole of the right kidney, there is
a region of cortical echogenicity, which likely corresponds to
an area of relative perfusion defect on the recent CT. The
appearance may represent a small evolving renal infarct.
Doppler studies show normal flow in the right main renal artery
and vein, as well as normal arterial flow in interlobar arteries
among the upper, middle, and lower poles. The resistive indices
range from 0.63-0.70 on the right.
On the left, the main renal artery and vein are also patent, but
interlobar arteries show slight parvus et tardus waveforms,
particularly when compared to the opposite side. The resistive
indices among the interlobar arteries range from 0.63-0.86. In
the setting of portable technique, the Doppler studies of the
left kidney are somewhat suboptimal, but the findings suggest
that there is likely somewhat decreased perfusion to the left
kidney compared to the right.
IMPRESSION:
1. Small echogenic region involving the cortex in the right mid
pole, which correlates with a region of relative decreased
perfusion on the recent CT. This appearance may represent an
evolving infarct within a portion of the right mid pole.
2. Patency of flow to both kidneys. However, Doppler studies are
suggestive of somewhat decreased perfusion to the left compared
to the right
[**2130-4-9**] 2:01 PM
CHEST (PORTABLE AP)
Single portable chest radiograph demonstrates no interval change
in the cardiomediastinal silhouette. There is increased
perihilar opacity involving the bilateral hila and mild diffuse
increased airspace opacity representing mild-to-moderate
pulmonary edema. There is blunting of the left costophrenic
angle representing a small effusion. The right costophrenic
angle is sharp. The trachea remains in the midline. Cardiomegaly
is unchanged.
IMPRESSION:
Cardiomegaly, unchanged.
Worsening CHF.
Brief Hospital Course:
Pt admitted [**2130-4-6**]
Stat lumbar drain placed - to decrease csf pressure less then 10
/ pt transfered to the SICU
A-line placed
Stroke service consulted / CT - reveals aortic dissection no
acute compression or infarct noted / the diseection and low BP
is thought to be responsible by decreasing the blood flow to the
spinal cord.
It is noticed if pts BP elevated, paralysis improves
Pt BP is kept elevated ( Pt also has ARF on admission ) / The
increase BP is probably due to decreasse blood flow to the
kidneys. / steroids started for ? acute cord infarction.
[**2130-4-7**]
Lumber drain stops working / replaced
troponin is increasing / pt started on beta blockers. The
increase troponin is thought to be due to hypoperfusion
syndrome.
[**2130-4-8**]
echo done
[**2130-4-9**]
Increase creat / BUN - renal consulted
[**2130-4-10**]
stable
[**2130-4-11**]
Diovan added for BP control
creat improves
Pt symptoms gradually improve with BP control
[**2130-4-12**]
Pt consult / fails voiding trial
Foley replaced
[**2130-4-13**]
Pt stable for DC
Medications on Admission:
Protonix
BP med
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>160: prn.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
paralysis with decrease bp
AA dissection
ARF
Discharge Condition:
stable
Discharge Instructions:
BP control 140-180
Moniter BUN creat
Followup Instructions:
Please follow-up with Neurology (Dr. [**Last Name (STitle) 2779**]
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2780**] [**Name (STitle) 2781**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2130-5-16**]
3:30
**This appointment is on the [**Location (un) **] of the [**Hospital Ward Name **] building.
You will need to call ahead of time to update your registration.
Please call [**Telephone/Fax (1) **]. Thank you.
Please call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]
Completed by:[**2130-4-13**]
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4745
} | Medical Text: Admission Date: [**2194-4-14**] Discharge Date: [**2194-5-15**]
Date of Birth: [**2117-10-8**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 96823**] is an unfortunate
76 year old gentleman unrestrained driver of an SUV who was
rear-ended at a moderate to high speed. The patient's car
jumped out of a curve and hit a brick wall with significant
front end damage. Air bags were deployed. The patient had
positive loss of consciousness with no recall of the events.
he was found by the paramedics and transferred here to the
[**Hospital1 69**] for further evaluation.
Upon arrival, he was complaining of face pain, neck pain and
shoulder pain. He denied any headache, chest pain or
shortness of breath. He had facial lacerations that were not
actively bleeding. He also had epistaxis of bilateral nares
with a right eyelid significant swelling.
His initial trauma evaluation revealed that he sustained
fractures of the nasal bones as well as the spleen, of C4 and
5 cervical spine with anterior widening of the fracture of
the right facet joint. He was stabilized in the Trauma Bay
and Neurosurgery Spine Service was called for consultation as
well as Ophthalmology and ENT. At that time, he was denying
blurry vision, numbness, weakness, tingling or any other
neurological symptoms. He was transferred to the Intensive
Care Unit for close monitoring and he was started on a
protocol.
He was electively intubated on [**4-15**] due to oropharyngeal
bleeding and high risk of aspiration with initiation of a
Propofol drip for sedation at that time. The patient was
transiently hypotensive to the low 60's over 30's with a map
of 40. This improved with fluids and adjustment of his
Propofol.
He was noticed to have a rise in his creatinine and while
awaiting cardiac clearance and a renal consultation, the
patient remained in the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Prostate cancer.
3. Status post brachy therapy.
4. History of breast cancer status post left mastectomy.
5. History of supraventricular tachycardia; he underwent a
pre-procedure catheterization which demonstrated 60 to 70%
mid left anterior descending with 50 to 60% proximal diagonal
to a 60% proximal right coronary artery. No percutaneous
transluminal coronary angioplasty was performed. He
underwent ablation for supraventricular tachycardia on [**2194-3-19**], for an atypical nodal re-entry.
6. The patient had a history of distant appendectomy.
7. Status post left hip replacement.
8. Status post bilateral inguinal hernia repair.
9. Status post left rotator cuff repair.
OUTPATIENT MEDICATIONS:
1. Tamoxifen.
2. Metoprolol.
3. Lisinopril.
4. Aspirin.
5. Magnesium oxide.
6. Verapasol.
7. Hydrochlorothiazide.
8. Colace.
9. Folate.
10. Colchicine.
11. Allopurinol.
12. Vitamin B12.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: He was a former smoker, quit in [**2161**]; drinks
one to two martinis every day.
PHYSICAL EXAMINATION: His examination upon admission, he had
a blood pressure of 196/90; heart rate of 80; respiratory
rate of 18; 99% on two liters nasal cannula; his temperature
was 98.6 F. In the Trauma Bay, he was awake, alert, oriented
times three, [**Location (un) 2611**] Coma Score of 15. Neck was in a
collar. He was noted to have a laceration on the left side
of the nose, hematoma in the right upper and lower eyelids,
bleeding from the nose more on the right than the left side,
bruise on the left eye, with no bleeding. His mouth and face
were stable. Trachea in the midline. No crepitus. Good
respiratory effort and clear to auscultation bilaterally.
Regular rate and rhythm. Abdomen was soft, nontender, no
scars. Pelvis was stable. Back showed no step-offs, no
tenderness to palpation. Rectal examination showed normal
tone, guaiac negative. Extremities with superficial
abrasions; all peripheral pulses were present.
LABORATORY: His hematocrit upon arrival was 38.4, white
blood cell count of 11.6 with a platelet count of 214. His
coagulation studies were within normal limits with a lactate
of 2.2. His gas showed a pH of 7.49, CO2 of 31, O2 of 82,
bicarbonate of 24 with a base excess of 1.
His chest x-ray was unremarkable. The cervical spine, as
stated above, showed a C4-5 sprain injury. Pelvis showed no
fractures.
A head CT scan showed a left temporal lobe subarachnoid
hemorrhage with a question of a small subdural hematoma in
the right temporal region. There was a right nasal bone
fracture. The chest CT scan and the abdomen shows some
degenerative joint disease of the thoracic spine and pleural
thickening, otherwise the rest of the scans were
unremarkable.
HOSPITAL PROGRESS AND COURSE: Mr. [**Known lastname 96823**], on [**4-18**], was
taken to the Operating Room by the Neurosurgical team after
cardiac clearance and underwent a C4-5 anterior fusion with
diskectomy and fixation. This included an open reduction of
a hyperextension injury followed by a C4-5 ALDF with a fibula
allograft and ventral screw plate fixation. This patient
tolerated well the complicated procedure and he was
transferred in stable condition to the Surgical Intensive
Care Unit.
His postoperative course was complicated by a peri-operative
myocardial infarction with a high troponin and
supraventricular tachycardia that required cardioversion.
Cardiology was again consulted and they recommended to start
him on Amiodarone as well as beta blockers.
Over the course of the next couple of days, he remained
waxing and [**Doctor Last Name 688**] hemodynamically speaking. He was not
spiking fevers and we tried to wean him off the ventilatory
support. On this effort, he was aggressively diuresed since
he was very positive after the surgery. He continued to
require suctioning multiple times on the different shifts and
he was producing fairly large amounts of bronchial
secretions.
The patient failed T-piece trials, especially due to the
increased bronchial secretions and it was decided clinically
at that time to place a tracheostomy. Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]
put a #8 Portex tracheostomy on [**2194-4-25**]. The patient
tolerated the procedure well.
Once the patient had a tracheostomy, he was able to wean much
easier and faster and by postoperative day number eight, he
was on 100% trache collar, tolerating it well with good O2
saturations. Around this time, he was much more awake than
prior days; he was following commands. He remained afebrile
with moderately elevated white count in the 15,000. He
continued to have massive amount of secretions requiring
suctioning from the nursing staff fairly frequently.
Multiple sputum samples were sent for culturing to the
Microbiology Laboratory but nothing grew out initially.
He started to spike temperatures and because of the
increasing amount of secretions he was started on
Levofloxacin empirically. Over the course of the next couple
of days, he was bronchoscoped multiple times and on the 10th,
a bronchial alveolar lavage sample was sent to Microbiology
and finally came positive for Methicillin resistant
Staphylococcus aureus. He was started on Vancomycin and the
Levofloxacin was discontinued.
Around this time, when the patient continued having increased
bronchial secretions, he had sporadic events of cardiac
arrhythmias presenting as supraventricular tachycardia to the
130s, always maintaining good blood pressure. Once again,
Cardiology recommended to continue the Amiodarone and the
beta blockers. On the night of [**5-5**], the patient
bradied down to the 40s, requiring Atropine to increase his
heart rate and the Amiodarone as well as the Lopressor was
held. The patient was started on Dopamine and Levophed to
keep his blood pressure, and a new Cardiology evaluation was
obtained. Their recommendation was to hold the Amiodarone
and the beta blockers and wean the pressors as tolerated.
By the next day he converted to normal sinus rhythm and he
was restarted on a lower dose of beta blockers, Lopressor
12.5 mg p.o. twice a day or three times a day if blood
pressure allowed.
A GJ tube was placed by Interventional Radiology and the
patient was started on tube feeds.
He continued to do well and defervesced from his spiking
temperatures. His tube feeds were advanced to Impact with
fiber at 90 cc with good tolerance and he was continued on
the antibiotic therapy.
His mental status continued to improve and by postoperative
day 23, tolerating tube feeds, being awake, appropriate,
following commands and less rhonchorous and not having as
much secretions as he was having in the previous days. He
was found to be stable enough to be transferred to the
Regular Floor to await rehabilitation placement.
The rest of his hospital course, once on the Floor, was
relatively uneventful, and finally today he was offered a bed
on the Rehabilitation Facility and he is being transferred to
this institution to continue his recovery. At the time of
discharge, the patient's list of medications included:
DISCHARGE MEDICATIONS:
1. Insulin sliding scale q. six hours.
2. Heparin 5000 units subcutaneously q. 12 hours.
3. Prevacid oral solution, 30 mg per GJ tube once a day.
4. Allopurinol 100 mg p.o. q. day.
5. Multivitamin 5 ml p.o. per GJ-tube q. day.
6. TUMS 500 mg per G-tube four times a day.
7. Aspirin 325 mg per G-tube q. day.
8. Lopressor 50 mg per G-tube twice a day.
9. Calcium, magnesium and potassium p.r.n.
10. Lasix 20 mg per G-tube twice a day.
11. Zoloft 50 mg per G-tube q. day.
12. Lorazepam 1 mg intravenous q. six hours p.r.n.
13. Intravenous Vancomycin 750 mg intravenously once a day,
was started on [**5-5**]. The recommendation is to continue
the Vancomycin for at least two weeks.
DISCHARGE INSTRUCTIONS:
1. The patient's diet consists at this time of tube feeds
that are Impact with fiber at 90 cc an hour continuously.
2. He is Methicillin resistant Staphylococcus aureus
positive.
3. Recommendation from Neurosurgery was to keep the patient
on the cervical hard collar until he follows up with
[**Hospital 4695**] Clinic and Dr. [**Last Name (STitle) 1327**] on [**2194-6-1**]. Up
until that time, the patient should not remove the cervical
collar by any means.
4. The patient will follow-up in the Trauma Clinic only as
needed.
CONDITION AT DISCHARGE: As stated above, the condition at
the time of discharge is stable.
DISCHARGE STATUS: Once again, as stated above, he should
make a follow-up appointment for Dr. [**Last Name (STitle) 1327**] in the
Neurosurgerical Clinic on [**2194-6-1**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2194-5-14**] 17:00
T: [**2194-5-14**] 17:51
JOB#: [**Job Number 96824**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4746
} | Medical Text: Admission Date: [**2123-1-25**] Discharge Date: [**2123-1-31**]
Date of Birth: [**2061-9-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
SOB; Transfer from OSH
Major Surgical or Invasive Procedure:
Intubation
A-line
History of Present Illness:
61 year old female with history of COPD on 3L home O2 (FEV1/FVC
33 FEV1 41%predicted), and newly diagnosed LUL mass with
negative cytology on trans-bronch bx, brushing, and BAL [**2122-12-9**]
recently admitted [**Date range (1) 82788**] for COPD exacerbation presents with
SOB. She has had trouble breathing over past 3 days but then
acutely worse at 3am when she reports the coughing began and
persisted for 14 hours staright. She went to [**Hospital **] Hospital,
gave her nebs, Solumedrol and Toradol and transferred here.
She was transferred to [**Hospital1 18**] ED given her care has been here.
On arrival to ED, vitals: 96.5 HR 82 BP 108/58 RR 18 98%2L. She
was oxygenating fine but uncomfortable per their report. CXR
showed no new infiltrate, stable LUL mass. ABG 7.39/57/189.
She was given nebs and azithromycin; but due to her discomfort
she was started on BIPAP which she did not tolerate well. She
was given ativan which improved her coughing/discomfort and was
able to remain on NC alone. She was subsequently transferred to
the MICU.
.
On arrival to the unit, Patient was in mild distress with
coughing and increased work of breathing, she was given
albuterol nebs and 0.5mg ativan wtih marked improvement. She
reports as above, worsening SOB over past 3-4 days that worsened
this AM. She denies fevers/chills, N/V, CP, or increased sputum
production. Denies new myalgias (has h/o fibromyalgia and
reports close to baseline pain). Denies sick contacts.
.
.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. LUL Lung Mass
-- s/p bronch w/brushings, BAL, and lymph nodes EBUS TBNA (neg
for malignancy)
2. Severe emphysema on 3L home O2; FEV1/FVC 33, FEV1
41%predicted
3. Recent Pneumonia - treated with azithromycin
4. Diastolic heart failure
5. Fibromyalgia
6. Tobacco Abuse
.
Past Surgical History
[**2122-12-9**]: Status post electromagnetic navigational bronchoscopy
with radial endobronchial ultrasound, transbronchial biopsy,
bronchoalveolar lavage, and brushing of the left upper lobe mass
as well as placement of fiducials x4 into the left upper lobe
lung mass.
Social History:
lives home alone, has two daughters, widowed x
2. Quit smoking last month when diagnosed with new lung mass,
prior smoked for 50 years. Retired. No ETOH in 17 years, no drug
use.
Family History:
brother with lung CA
Physical Exam:
Temp 96.0 141/72 80 29 96% NRB @15L
General Appearance: Anxious, slight respiratory distress
coughing
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: , Wheezes : , Diminished: ), poor air movement
throughout
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admission:
[**2123-1-25**] 03:15PM BLOOD WBC-10.3 RBC-3.54* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.1 Plt Ct-189
[**2123-1-25**] 03:15PM BLOOD Glucose-157* UreaN-21* Creat-0.7 Na-138
K-4.8 Cl-98 HCO3-30 AnGap-15
[**2123-1-25**] 03:15PM BLOOD proBNP-89
[**2123-1-25**] 03:15PM BLOOD Calcium-8.4 Phos-3.2 Mg-2.2
[**2123-1-25**] 04:29PM BLOOD Type-ART PEEP-6 O2 Flow-50 pO2-198*
pCO2-57* pH-7.39 calTCO2-36* Base XS-8
CXR: [**1-25**]
IMPRESSION:
1. No acute cardiopulmonary process.
2. Unchanged left upper lobe spiculated mass.
CT CHEST: [**1-26**]
FINDINGS: 6.6 x 1.6 cm left upper lobe lesion is less dense and
has slightly decreased in size since [**2122-12-2**] when it measured
6.6 x 3 cm. There is stable mild left upper lung traction
bronchiectasis. There is near complete resolution of a right
middle lobe (4:106) opacity measuring under 5 mm. 2.8 x 5 mm
consolidation near the left upper lobe fissure is unchanged
since [**2122-12-2**]. Severe centrilobular emphysema is unchanged since
[**2122-12-2**]. There is no pleural effusion. ET tube tip is 1 cm above
the carina. An NG tube courses through the esophagus and stomach
with its tip outside the plane of imaging.
Heart size is normal. The main pulmonary artery measures 3.2 cm
in diameter. Scattered enlarged mediastinal nodes measuring up
to 1.2 cm in diameter are little change since [**2122-12-2**].
Although this exam was not tailored for subdiaphragmatic
diagnosis, the imaged intra-abdominal organs are unremarkable.
Bone windows demonstrate no lesion concerning for metastasis or
infection.
IMPRESSION:
1. Given minimal improvement and benign histology of spiculated
left upper
lobe mass followup in 6 months can be obtained.
2. Resolution of opacity in the right lung at the junction of
the major and minor fissure.
3. Stable severe centrilobular emphysema.
4. ET tube tip is just above the carina in this study, but is in
satisfactory position on chest radiograph performed 6 hours
after and thus does not need to be repositioned.
Brief Hospital Course:
61 year old female with COPD on 3L home O2 s/p recent admission
[**12-2**] for COPD exacerbation and newly diganosed LUL mass now
admitted with respiratory distress.
.
#. Acute hypercarbic respiratory distress/Cough: On admission,
the patient was complaining of 3 days of cough and SOB that
acutely worsened overnight. She presented to an OSH and was
transferred to the [**Hospital1 18**] ED for further managment. She was
placed on BiPAP in the ED and transferred to the MICU. She had
hypercapneia with a PCO2 of 57 initially, and was placed on non
rebreather mask with little improvement, and was then started on
non invasive positive pressure ventilation. Patient however
tolerated this poorly and required intubation for severe
respiratory distress.
During acute decompensation, It was noted that patient was
taking very high frequency shallow breaths with a constant cough
like sound generated in the upper airway. Patient was relatively
easy to ventilate and this raised question of paradoxycal vocal
cord dysfunction, phrenic nerve injury, etc. During intubation
however, vocal cords were noted to be normal in appearance and
during serial imaging diaphragms remained symmetrical.
Patient was treated with pulse dose steroids and started on
Azithromicyn. Given known left upper lobe nodule, a CT scan of
the chest was performed and did not show any significant
interval change. Patient was sucessfully extubated on [**1-28**] with
short NIVPPV bridge. Patient was transfered to medical floor on
[**1-28**]. She had an uneventful course and was discharged in stable
condition.
Pt has been having financial problems and has not been able to
afford Tiotropium (Spiriva). Social work was consulted and she
was given Ipratropium instead.
Patient was slowly weaned off steroids with taper over the next
2-3 weeks.
#. Fibromyalgia: Difficult to control, with overt anxiety in
spite of [**Hospital 17073**] medical regimen. We continued regimen with
fentanyl patch, gabapentin, SOMA, darvocet, amitryptline and
Propoxyphene
#. Anxiety: Patient with many social stressors and difficult to
control anxiety. Given progression of symptoms inspite of
agressive therapy, she was to follow up her outpatient
psychiatrist to address her anxiety.
# Anemia: During admission noted to be near baseline of 31.
There was no overt bleeding or hemolysis.
Medications on Admission:
Amitriptyline 150mg qhs
aspirin 81 daily
Darvocet A[**Telephone/Fax (3) **] q6 prn
duonebs
valium 5mg TID
fentanyl patch 25mcg q72 hr
flurbiprofen 100mg TID
lasix 80mg daily
gabapentin 900mg TID
hydrocodone-acetaminophen 5-500 [**Hospital1 **] prn pain
Potassium Chloride 8mEQ QID
Pulmicort
Soma 350mg TID
MVI
Omega 3
Discharge Medications:
1. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Darvocet A[**Telephone/Fax (3) **] mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for fever or pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
9. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
12. Pulmicort Inhalation
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Flurbiprofen 100 mg Tablet Sig: One (1) Tablet PO three
times a day.
16. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
17. Prednisone 5 mg Tablet Sig: see directions Tablet PO once a
day for 2 weeks: take 8 pills on [**2123-1-31**], then take 6
pills on [**2-26**], then take 4 pills on [**2123-2-7**],
then take 2 pills on [**3-6**], then take 1 pills on
[**3-10**].
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
COPD exacerbation
Fibromyalgia
Lung mass
Possible h/o diastolic heart failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You came to the hospital with shortness of breath that is likely
due to COPD exacerbation. As you were tiring out, we put you
temporarily on a ventilator to help you breath. You recovered
after one day and returned to your baseline functional status.
We found on CT scan a lung nodule that needs to be followed up.
Please see f/u appointments. You were discharged in stable
condition.
.
Please follow up with your doctors, see below.
Followup Instructions:
Please follow up with Chest CT scan for the lung nodule in 6
month.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83672**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2123-2-19**] 10:30
ICD9 Codes: 2762, 4280, 2768, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4747
} | Medical Text: Admission Date: [**2131-12-4**] Discharge Date: [**2131-12-8**]
Date of Birth: [**2103-9-8**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
headache, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
28 yo M w/ no significant [**Hospital 3262**] transferred from [**Hospital3 25148**]
Center with headache, fever, neck pain, and vomiting for
continued management of likely meningitis. Patient's history
dates back to [**Month (only) **] when he was experiencing cough and low
grade temperatures, for which he was treated with azithromycin.
He continued to have on/off fevers and on [**2131-11-26**] presented to
[**Hospital3 25148**] Center ED with complaints of ? headache,
photophobia, nausea, and vomiting. Tests were sent inlcuding:
monospot neg, strep neg, infleunza negative, CXR negative, urine
cx negative, blood cx negative, and throat cx negative. He had
a normal CBC. He received IVF and no antibx and was discharged
home. He returned the following day and that time was treated
with ceftriaxone and again sent home pending cultures (lyme
negative, hep B ?, ESR 30, bcx x 2, wbc 6.8). He then went to
see his PCP the following day for a F 101.4 and non-petechial
macular rash. At that time he was started on levofloxacin and
instructed to present to the hospital for admission if he
continued to have fevers on this antibiotic. He represented to
[**Hospital3 25148**] Center ED the following day and underwent an LP
which showed: wbc 724, rbc 69, glu 53, TP 97, gram stain: 4+
PMNs, no organisms. Other tests done:
MRI: mild left mastoiditis.
Mycoplasma IgM negative, IgG positive.
CXR: LLL atelectasis vs PNA.
He was admitted to the ICU, ID was consulted and he was started
on vanc/doxy/rifampin. Given continued fevers, decision was
made to transfer the patient to [**Hospital1 18**] for continued care.
Past Medical History:
# hypercholesterolemia
# s/p T&A
# s/p recent URI tx with azithromycin [**9-30**]
Social History:
Denies tobacco, Etoh, illicits. Married and his wife is
currently pregnant. Works as a music teacher at [**Location (un) **]. He
is active outdoors and was last outside in early/mid [**Month (only) **].
He denies history of tick bites. He is sexually active with 1
partner (his wife). No history of STDs. No recent travel. No
unusual foods.
Family History:
Mother has epilepsy, dx age 15
Physical Exam:
T 100.1 bp 127/66 hr 85 rr 23 O2 96% RA
genrl: appears fatigued but not toxic
heent: anicteric, eomi, perrla, mild pharyngeal erythema and
petechiae
neck: supple, no LAD
cv: rrr, normal S1/S2
Lungs: CTA bilaterally
Abd: nabs, soft, nt/nd, no HSM
Extr: no [**Location (un) **]
Neuro: A, Ox3, CN 2-12 grossly intact, sensation and strength
normal throughout
Pertinent Results:
[**2131-12-4**] 09:28PM GLUCOSE-97 UREA N-10 CREAT-0.6 SODIUM-130*
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-25 ANION GAP-12
[**2131-12-4**] 09:28PM ALT(SGPT)-57* AST(SGOT)-52* LD(LDH)-322* ALK
PHOS-122* TOT BILI-0.6
[**2131-12-4**] 09:28PM ALBUMIN-3.0* CALCIUM-8.9 PHOSPHATE-3.1
MAGNESIUM-2.4
[**2131-12-4**] 09:28PM WBC-13.5* RBC-3.90* HGB-11.5* HCT-33.4*
MCV-86 MCH-29.5 MCHC-34.6 RDW-13.6
[**2131-12-4**] 09:28PM NEUTS-83.2* LYMPHS-10.1* MONOS-4.6 EOS-1.9
BASOS-0.1
[**2131-12-4**] 09:28PM PLT COUNT-477*
[**2131-12-4**] 09:28PM PT-19.1* PTT-32.1 INR(PT)-1.8*
FDP 0-10, FIBRINOGEN 442
RETIC 1.2%, IRON 38, TIBC 172, FERRITIN 610, FOLATE 10.4, B12
1203, TSH 0.96
ALBUMIN 3.0, VANCO TROUGH 16.1
.
HEPATITIS B S AG: NEGATIVE, S AB: POSITIVE, C AB: NEGATIVE
HEPATITIS C AB: NEGATIVE
HIV ANTIBODY: NEGATIVE
.
PA and lateral upright chest radiograph was reviewed. The heart
size is normal. Mediastinum has normal position, contour and
_____. The left lower lobe consolidation in the posterior basal
segment of the lobe is demonstrated accompanied by small pleural
effusion. The rest of the lung is unremarkable.
IMPRESSION: Left lower lobe pneumonia. Small amount of pleural
effusion.
.
Anaplasma Phagocytophilum and Ehrlichia Chaffeensis Ab panel
Ehrlichia Chaffeensis Antibody, IFA
E. Chaffeensis IgG Titer 1:64 (H)
E. Chaffeensis IgM Titer <1:20
Interpretation: PAST INFECTION
.
Anaplasma Phagocytophilum (HGE [**Doctor Last Name **]) IgG/IgM Ab, IFA
A. Phagocytophilum IgG Titer <1:64
A. Phagocytophilum IgM Titer <1:20
Interpretation: Antibody Not Detected
.
RMSF IGG NEGATIVE NEGATIVE
RMSF IGM NEGATIVE NEGATIVE
RMSF IGG TITER TNP-SCREENING TEST <1:64
NEGATIVE. TITER
NOT PERFORMED.
RMSF IGM TITER SEE BELOW <1:64
TNP-SCREENING TEST NEGATIVE. TITER NOT PERFORMED.
Brief Hospital Course:
# Meningitis: Initial DDX included most likely bacterial,
perhaps due to invasive strep pneumo given concurrent lobar
pneumonia; possibly viral given enteroviruses and adenoviruses
still prevalent due to the unusual winter; and less likely
zoonotics such as Rickettsia or ehrlichia (unlikely given
relatively short incubation periods with a rather distant
outdoor exposure). CSF culture was negative, likely due to
pretreatment with antibiotics. Rickettsial and ehrichia
antibodies do not suggest current, active infection. Lyme
antibodies at the outside hospital were negative. Patient had
significantly improved on the vanco/rifampin/doxy started at the
OSH. ID recommended completing a 14 day course of meropenem
(reportedly covers Listeria; NO similar data for erbapenem),
vancomycin (q8h, vanco trough 16.1), and doxycycline. A PICC
was placed for IV access for long term antibiotics.
.
# Rash/joint pain: Suspect serum sickness vs secondary to above
infection. Patient's symptoms steadily improved with above
treatment.
.
# Transaminitis: Suspect this is due to serum sickness vs above
infection. Hepatitis B serologies consistent with prior
immunization and hepatitis C antibody negative. HIV antibody
was negative. Statin was held. On the day of discharge: ALT
104, AST 73. Consider outpatient imaging for possible NASH if
abnormalties persist.
.
# Coagulopathy: Likely nutritional. INR improved from 1.8->1.4
with vitamin K supplementation. [**Month (only) 116**] be secondary to hepatic
dysfunction. DIC panel was otherwise normal.
.
# Thrombophlebitis: Patient developed multiple sites of
thrombophlebitis related to peripheral IVs. With hot packs and
elevation, the redness and swelling improved. He was instructed
to continue hot packs and elevation and to notify his PCP or to
go to the local ER if swelling or erythema worsened to rule out
a subsequent DVT.
.
# Normocytic anemia: Hematocrit remained stable at 31-33. Low
retic may be suggestive of BM suppression from active infection.
High ferritin suggestive of anemia of chronic disease. Folate,
B12 normal. Recommend PCP [**Name9 (PRE) 702**] for continued monitoring.
.
# Hypercholesterolemia: Statin held. Patient will follow-up
with his PCP to restart this medication once his LFTs normalize.
.
# PPX: SQ heparin
.
# FEN: Given low albumin and poor po intake, patient was advised
to take boost supplements [**Hospital1 **] until his po intake improves back
to normal
.
# Dispo: Patient discharged home with services for IV
antibiotics
Medications on Admission:
(on transfer):
doxycycline 200 mg IV q12h
cefotaxime 2 g IV q6h
dilaudid PCA
albuterol nebs
guiafenesin prn
toradol
zofran
hydroxazine
tylenol
benadryl
promethazine
reglan
(home):
simvastatin 40
levofloxacin 750 mg po qd
Discharge Medications:
1. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q8H (every 8 hours) for 5 days: through [**2131-12-13**].
Disp:*16 Recon Soln(s)* Refills:*0*
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 8H (Every 8 Hours) for 5 days: through [**2131-12-13**].
Disp:*16 gram* Refills:*0*
3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
4. PICC LINE CARE, PER PROTOCOL
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
meningitis, organsim unknown
left lower lobe pneumonia, organism unknown
thrombophlebitis
transaminitis with negative hepatitis panel and negative HIV
normocytic anemia
drug rash
Discharge Condition:
good: afebrile, symptomatically much improved, taking good po
Discharge Instructions:
Please call your doctor or go to the emergency room for
temperature > 101, worsening headache, light sensitivity, neck
stiffness, diarrhea, rash, worsening swelling/pain/redness in
your arms, or other concerning symptoms.
Please follow-up with your primary care doctor to monitor for
diarrhea, to follow-up your anemia (low blood count), and to
discuss further tests for your abnormal liver enzymes.
Please follow a low cholesterol diet.
Please note the following changes in your home medications:
1. You have been started on 3 antibiotics: vancomycin,
meropenem, and doxycycline. Please take these, as prescribed.
2. Please do not take your simvastatin until you have your liver
enzymes rechecked by your primary care doctor.
Followup Instructions:
Please call to schedule follow-up with Dr. [**Last Name (STitle) 71166**] within 1 week
of discharge. Phone: [**Telephone/Fax (1) 63696**]
ICD9 Codes: 486, 2761, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4748
} | Medical Text: Admission Date: [**2148-2-9**] Discharge Date: [**2148-2-22**]
Date of Birth: [**2070-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain and distention
Major Surgical or Invasive Procedure:
[**2148-2-10**]: Triple Lumen Subclavian; Central Venous Catheter
Insertion in VICU
History of Present Illness:
77 yo F w/ CAD, CABG in [**2142**], CHF (EF 10-15%), 2+MR, A.fib, HTN,
DM2, dementia admitted to [**Hospital1 18**] on [**2148-2-9**] to surgery for eval
of severe L sided colitis/ IBD. Now transferred to MICU for
management of CHF, respiratory failure. Pt. was initially
admitted to OSH on [**3-4**] for c.diff and IBD and discharged on
po vanco and asacol to rehab. On [**2-8**] pt. had increased abd
distension, pain and bloody stools. At an OSH, CT was signif.
for severe L sided colitis. Subsequent Sigmoidoscopy showed
showed severe colitis to 40cm worrisome for ichemia vs. colitis.
On transfer to [**Hospital1 18**] pt. was started on po vanc, amp, cipro,
flagyl for broad spectrum coverage. On [**2-11**] pt. had an episode
of <6beats of NSVT. On [**2-13**] pt. was triggered for A.fib w/ RVR
and SOB [**2-3**] pulm edema. She was given lasix 20 IV and
transferred to the SICU for a lasix GTT. An echo showed severe
LV hypokinesis, EF of [**10-16**]%, grade III/IV LV diastolic dysfxn.
2+MR and mild PAH. Cardiology was consulted. The pt. was started
on amiodarone for rate control of AF. The heart failure service
was consulted and recommended anticoagulation for afib when safe
and milrinone for inotropy. On [**2-15**] the pt. was in resp.
distress and was intubated. The cxr on [**2-16**] indicates bilateral
upper lobe consolidations worrisome for PNA. Pt. was started on
cefepime in addition to other abx.
Past Medical History:
Peripheral Vascular Disease
Anemia secondary to Lower Gastrointestinal Bleed
C. Diff - currently on treatment with Vancomycin orally
Dementia
Cardiomyopathy
Hypertension
Myocardial Infarction
Left BBB on EKG
Coronary Artery Disease
Depression
Urinary Tract Infection with Escherichia coli - was treated with
Levoquin IV and Macrobid to be d/c [**2148-2-12**].
Diabetes Mellitus - Type II
Old CVA
h/o CEA
.
PSH:
[**2142**]: CABG
Left knee surgery
Left 1st toe amputation for gangrene
Appendectomy
Social History:
No history of smoking or alcoholism. Nursing home resident for
the last 4-5 months. Patient has a very caring daughter and
sister who manage the [**Hospital 228**] healthcare.
Family History:
NA
Physical Exam:
Height: 62inches
Weight: 82kg
PE: 100.4, 122, 104/50, 16, 97%RA
GEN: NAD
CARD: IRRR, well-healed sternal scar.
LUNGS: CTAB
ABD: distended, soft, somewhat tender left lower quadrant
without rebound tenderness or guarding. No hernias. Guaiac
positive, no masses on rectal exam.
EXT: palpable 2+ femoral pulses, wwp distally.
Pertinent Results:
[**2148-2-10**] 10:24AM BLOOD WBC-10.4 RBC-3.00* Hgb-8.9* Hct-26.7*
MCV-89 MCH-29.8 MCHC-33.5 RDW-14.7 Plt Ct-543*
[**2148-2-10**] 10:14PM BLOOD Neuts-82* Bands-1 Lymphs-11* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2148-2-11**] 08:45AM BLOOD Neuts-87* Bands-2 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-2* Myelos-0
[**2148-2-10**] 08:50AM BLOOD PT-14.7* PTT-32.0 INR(PT)-1.3*
[**2148-2-10**] 08:50AM BLOOD Glucose-104 UreaN-8 Creat-0.5 Na-134
K-4.1 Cl-107 HCO3-21* AnGap-10
[**2148-2-10**] 08:50AM BLOOD ALT-15 AST-21 AlkPhos-53 Amylase-34
TotBili-0.2
[**2148-2-11**] 08:00PM BLOOD CK(CPK)-22*
[**2148-2-12**] 03:40AM BLOOD CK(CPK)-21*
[**2148-2-12**] 01:06PM BLOOD CK(CPK)-26
[**2148-2-10**] 08:50AM BLOOD Lipase-20
[**2148-2-10**] 10:14PM BLOOD Lipase-25
[**2148-2-11**] 08:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2148-2-12**] 03:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2148-2-12**] 01:06PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2148-2-10**] 08:50AM BLOOD Albumin-2.4* Calcium-7.3* Phos-2.6*
Mg-1.7
[**2148-2-14**] 05:20PM BLOOD Triglyc-70
[**2148-2-14**] 01:37AM BLOOD Digoxin-0.5*
[**2148-2-18**] 05:17AM BLOOD Vanco-25.1*
[**2148-2-11**] 08:21PM BLOOD Type-ART pO2-62* pCO2-29* pH-7.49*
calTCO2-23 Base XS-0 Intubat-NOT INTUBA
[**2148-2-13**] 06:40AM BLOOD Lactate-3.7*
[**2148-2-13**] 06:40AM BLOOD freeCa-1.07*
[**2148-2-10**]: 1. Diffuse colitis predominantly involving the mid
transverse colon to the rectosigmoid. Differential etiologies
include both infectious and ischemic causes, [**Female First Name (un) 899**] territory.
2. Moderate ascites. No intra-abdominal or intrapelvic abscess.
3. Diffuse atherosclerotic calcification of the aorta, renal
arteries, celiac, and SMA. The celiac and SMA do opacify with
contrast. The [**Female First Name (un) 899**] is not identified.
4. Small bilateral pleural effusions and bibasilar atelectasis.
.
ECHO [**2148-2-13**]: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is severe global left ventricular
hypokinesis (LVEF = 10-15%). No masses or thrombi are seen in
the left ventricle. Transmitral Doppler and tissue velocity
imaging are consistent with Grade III/IV (severe) 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. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe left ventricular systolic and diastolic
dysfunction. Moderate mitral regurgitation. Trivial pericardial
effusion. Mild pulmonary hypertension.
.
CXR [**2148-2-19**]: The linear lucency seen medially in the right upper
lobe in prior study is no longer present. Otherwise this
examination is with no other changes with cardiomegaly,
asymmetric mild interstitial pulmonary edema with more focal
consolidation in the right upper lobe, and bilateral pleural
effusions with associated atelectasis in the bases worse in the
left side.
Brief Hospital Course:
A/P: 77 yo F w/ cardiogenic shock, CHF (EF 10-15%), CAD, HTN,
a.fib, DMII, ischemic colitis. On Cefepime, amp, flagyl, cipro,
vanc po and iv. Transferred to micu for management of CHF,
respiratory failure.
.
# Cardiogenic shock/CHF: Patient had ECHO on admission that
revealed severe LV dysfunction with EF of [**10-16**]%. She
transiently required milrinone to improve cardiac output. CHF
thought to be of multifactorial etiology in setting of CAD,
tachyarrythmia, sepsis. Patient improved with lasix gtt and was
weaned off milrinone as she was hemodynamically stable.
Continued on ACE inhibitor and Beta blocker for afterload
reduction. Patient was at her estimated dry weight at time of
discharge.
.
#Ischemic colitis: pt. admitted with colitis of unclear
etiology. Ruled out x 3 for C diff.. CT abd/pelvis revealed
diffuse atherosclerotic calcifications of both renal arteries
and the celiac and superior mesenteric axis. The etiology was
felt to be ischemic in nature secondary to calcification of
vessels. Due to her other comorbidities, she was deemed not a
surgical candidate. PO vancomycin and flagyl was discontinued.
She was not started on platel as this is contraindicated in
congestive heart disease.
.
# Respiratory failure: Pt. required intubation secondary to
hypoxia and respiratory distress. CXR shows right upper lobe>LUL
consolidation, as well as hilar consolidation. However, BAL was
done and was negative. Patient was afebrile with normal WBC
count. Therefore antibiotics were discontinued. Respiratory
distress was felt to be secondary to pulmonary edema in setting
of rapid atrial fibrillation. Therefore, patient was diuresed
and subsequently extubated without complication.
.
# Atrial fibrillation: On amiodarone and beta blocker for rate
control. Anticoagulation was held initially as patient had
bright red blood per rectum secondary to colitis. Hematocrit
remained stable and patient was restarted on coumadin prior to
discharge with monitoring of her INR.
.
# CAD: Patient is s/p CABG in [**2142**]. She was continued on medical
regimen of betablocker, aspirin, ACE- inhibitor while in house.
.
# IBD: continued mesalamine dr 800mg po tid
.
# DMII: QID finger sticks and ISS while in house.
.
# dementia: continued donepezil;
.
# depression: continued duloxetine 60 [**Hospital1 **], ritalin initially
held and restarted.
.
# skin breakdown- skin care for sacral decubitus.
.
# F/E/N: Evaluated by speech and swallow team after extubation.
Recommended pureed diet with thin liquids and crushed meds in
apple sauce.
.
# PPx: Bowel regimen, PPI, heparin GTT
# Code Status: DNR/DNI; at time of discharge patient's family
was very interested in hospice level care. Case Management
discussed options with family and plan was to contact nursing
facility to make them aware of transition to hospice level care.
.
# Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (1) 77488**], cell
number is [**Telephone/Fax (1) 77489**].
.
Medications on Admission:
Medication at Nursing Home (prior to hospital admission)
Vancomycin 250mg po four times a day on taper dose
Lisinopril 30mg daily
Asacol 800mg twice a day
Ritalin 25 QAM/30 QPM
Cymbalta 60mg twice a day
Macrobid 100 twice a day
Iron 325mg twice a day
Aricept 5 QHS
Coreg ___ twice a day
Remeron 30mg QHS
Plavix 75mg daily
ASA 81mg daily
Lactobacillus two tablets twice a day
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Ischemic colitis, Acute decompensated systolic heart
failure, EF 15%, atrial fibrillation
Secondary: Coronary artery disease, Diabetes mellitus, Dementia
Discharge Condition:
Vital signs stable, pain free
Discharge Instructions:
You were admitted to the hospital with abdominal pain and found
to have inflammation in your colon due to calcification of the
blood vessels in your abdomen. You had fluid build up in your
lungs which temporarily required a breathing tube. You were
given medication to help remove the fluid. You will be returning
to the same long term facility and you should continue to
explore options for hospice as your family had expressed the
wish to do so.
.
Please contact your doctor if you develop any worrisome
symptoms.
ICD9 Codes: 4254, 486, 4280, 311, 4019, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4749
} | Medical Text: Admission Date: [**2187-8-15**] Discharge Date: [**2187-8-22**]
Date of Birth: [**2143-11-3**] Sex: F
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
1-2days jaudice, nausea and mild RUQ on palpation on [**2187-8-15**]
Major Surgical or Invasive Procedure:
ERCP with stent placement was performed on [**2187-8-16**]
History of Present Illness:
This a 43 year old female with metastatic breast cancer, to
liver, lung, brain, and bone who presented with 1-2days jaudice,
nausea and mild RUQ on palpation on [**2187-8-15**]. In the ED, a RUQ U/S
was unable to identify the CBD but it did show dilatation of the
pancreatic duct which was suspcious for CBD stone. ERCP with
stent placement was performed on [**2187-8-16**]. Patient was treated
with IV Ciprofloxacin and stable on the OMED service until the
early am of [**2187-8-19**] when patient was found to be hypotensive to
SBP 70s, hypothermic to 95, with a rising lactate of 4.2.
Patient received 3L IVF boluses and blood pressure remained
fluid responsive.
.
Patient reported feeling the worst of her stay this am but
denies localizing symptoms. She denies RUQ pain, fevers, chills,
nausea, vomiting, cough, urinary urgency or frequency, dysuria,
or SOB. No HA or confusion. Of note, she has chronic back pain
that is unchanged from baseline.
.
Onc History:
Recurrent breast CA dx'd [**2181**] tx'd w/ lumpectomy/XRT/ CA.
[**7-17**]: XRT for osseous disease. She then rec'd wkly taxol/[**Doctor Last Name **]/
herceptin until markers went down to normal range. She was on
q3w Herceptin from [**12/2184**] - [**4-/2186**], when she developed brain
mets and consented to trial 06-356 combining Lapatinib 1000mg QD
with whole brain radiation then Lapatinib with weekly Herceptin.
She progressed and was changed to Xeloda- Lapatanib
w/progression. After cyberknife she was tx'd w/
Herceptin/Navelbine for 4 doses. Recent Brain MRI shows 2 small
new lesions for which she had Cyberknife tx.
In [**Month (only) 116**] she Avastin/ Gemzar therapy but developed thigh pain and
impending femur fx was discovered requiring surgery and XRT to
right leg. Recent MRI with 3 new small brain lesions, s/p
cyberknife to brain [**6-19**]. Known L4 compression fracture, being
evaluated for XRT.
Past Medical History:
Breast cancer - as above
S/p cholecystectomy
Chronic Back Pain L4 compression fracture
Social History:
She lives with her husband and two children.
Previously worked as a hostess. Tob: 20 pack-yr, quit 10 yrs ago
Family History:
PGM had breast cancer in her 70s
Mother and Father have hyperlipidemia
Physical Exam:
Vitals: T: 97.3 BP:138/49 HR:112 RR:26 O2Sat: 98% on 4L
GEN: Chronically ill appearing female, hirsuit, obese
HEENT: EOMI, PERRL, + sclera icterous, no epistaxis or
rhinorrhea, DMM
NECK: unable to assess JVD [**1-13**] neck girth, carotid pulses brisk,
no bruits, no cervical lymphadenopathy, trachea midline
COR: Tachy, regular, HS distant no M/G/R, normal S1 S2, radial
pulses +1
PULM: Expiratory wheezes, BS distant, decreased BS at right base
ABD: Soft, +RUQ TTP, ND, +BS, no rebound or guarding
EXT: 2+ pitting edema to sacrum. No C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Attention
intact - spells world backwards. CN II ?????? XII grossly intact.
Moves all 4 extremities. Generalized weakness but strength 4+/5
in upper and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. Unable to assess gait.
SKIN: + jaundice, no cyanosis, or gross dermatitis. +
ecchymoses.
Pertinent Results:
On Admission:
[**2187-8-15**] 03:05PM WBC-2.6* RBC-2.92* HGB-9.2* HCT-27.6* MCV-95#
MCH-31.7 MCHC-33.4 RDW-20.8*
[**2187-8-15**] 03:05PM NEUTS-47* BANDS-21* LYMPHS-10* MONOS-16*
EOS-4 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1*
[**2187-8-15**] 03:05PM PLT SMR-VERY LOW PLT COUNT-71*
[**2187-8-15**] 03:05PM GLUCOSE-63* UREA N-11 CREAT-0.3* SODIUM-136
POTASSIUM-3.0* CHLORIDE-93* TOTAL CO2-31 ANION GAP-15
[**2187-8-15**] 03:05PM ALT(SGPT)-49* AST(SGOT)-101* ALK PHOS-747*
TOT BILI-15.8* DIR BILI-12.2* INDIR BIL-3.6
[**2187-8-15**] 03:05PM ALBUMIN-2.7* CALCIUM-8.3* PHOSPHATE-3.6
MAGNESIUM-1.8
[**2187-8-15**] 03:05PM LIPASE-145*
[**2187-8-15**] 03:15PM LACTATE-2.3*
RUQ ultrasound - Limited examination, but no evidence of biliary
ductal
dilatation.
Brief Hospital Course:
On transfer to the [**Hospital Unit Name 153**]
# Hypotension - Patient met SIRS criteria with T < 96 and SBP<70
on the floor prior to transfer which resolved with 3L IVF bolus
and broadening of antibitoics to include vancomycin and zosyn.
Likely source is biliary duct obstruction but also has
long-standin effusion and line as possible sources. Patient with
right porta-cath as only access. No central venous line placed
as patient's goal of care were clarified. Initially on pressors
and IV fluid boluses to maintain adequate MAP and urine output.
decision to d/c once clear that patient was CMO given widely
metastatic breast CA. Patient was started on IV morphine drip.
Antibiotics were continued for comfort. Other unnecessary
medications/diagnostic studies were discontinued. family was all
around and present and patient passed away [**2187-8-21**].
Medications on Admission:
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg PRN
.
Meds on transfer:
Ciprofloxacin 400mg IV Q12H
Albuterol nebs Q6H prn
Chlorhexidine oral rinse [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Heparin SC TID
Hydrocortisone 100mg IV Q8H
Ipratropium Neb Q6H prn
Magnesium sliding scale
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg Q4H prn
Pantoprazole 40mg po Q24H
Zosyn 4.5mg IV Q8H day#1 [**8-19**]
Potassium sliding scale
Prochlorperazine 10mg Q6H prn
Senna 1 tab po BID
Vancomycin 1000 mg IV Q 12H D#1 [**8-19**]
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic breast cancer
Discharge Condition:
death
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2187-8-22**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4750
} | Medical Text: Admission Date: [**2191-10-28**] Discharge Date: [**2191-10-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old woman history of depression, hypothyroid,
osteoarthritis recently moved to [**Hospital **] Rehab presenting with
increasing dyspnea and hypoxemia. Per record she was found to be
very sleepy but arousable with SOB and non-productive cough. VS
at NH were 128/83 112-140 78%/3L -> 90%/5L. Per EMS noted to
have cough productive of brown sputem. No documented fevers.
.
In the ED, initial vs were 98.0 hr 145 bp 134/88 rr 24 O2 sat
100/NRB 15L. ABG 7.26/84/262/39, Lactate 0.8, WBC 11.6. She was
started on levoquin and vancomycin.
.
On arrival in the ICU she had labored breathing on a face mask
with NIPPV. She was barely arousable but able to follow simple
commands.
.
Review of systems:
(+) Per HPI +dyspnea, +cough
(-) Unable to reliable obtain, per [**Hospital **] Rehab admission
+constipation (regularly disimpacts), chronic weakness, anxiety
and depression
Past Medical History:
neck cancer with remote surgery
depression
osteoarthritis
hypothyroidism
dyslipidemia
anemia
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
NC
Physical Exam:
t95 hr 110 bp 102/62 spO2 90% on FiO2 100%
General: dyspneic, in respiratory distress, barely arousable
HEENT: dry MM
Neck: large mass on left neck
Lungs: crackles throughout most pronounced at bases
CV: irregular with systolic murmur unable to further
characterize
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: cold, weak but palpable distal pulses, no edema
Pertinent Results:
On admission:
[**2191-10-28**] 12:20PM BLOOD WBC-11.6*# RBC-3.77* Hgb-11.6* Hct-34.9*
MCV-92 MCH-30.6 MCHC-33.1 RDW-13.4 Plt Ct-472*
[**2191-10-28**] 12:20PM BLOOD Neuts-87.3* Lymphs-8.4* Monos-4.0 Eos-0.2
Baso-0.2
[**2191-10-29**] 02:42AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Stipple-OCCASIONAL Envelop-OCCASIONAL
[**2191-10-28**] 12:20PM BLOOD PT-13.5* PTT-23.9 INR(PT)-1.2*
[**2191-10-28**] 12:20PM BLOOD Glucose-157* UreaN-28* Creat-0.5 Na-139
K-4.7 Cl-95* HCO3-33* AnGap-16
[**2191-10-28**] 12:20PM BLOOD cTropnT-0.02*
[**2191-10-28**] 12:20PM BLOOD Calcium-8.0* Phos-4.9* Mg-2.2
[**2191-10-28**] 12:21PM BLOOD Type-ART Rates-/30 FiO2-100 pO2-262*
pCO2-84* pH-7.26* calTCO2-39* Base XS-7 AADO2-371 REQ O2-66
Intubat-NOT INTUBA Comment-BIPAP
[**2191-10-28**] 12:21PM BLOOD Glucose-152* Lactate-0.8 Na-141 K-4.5
Cl-91*
[**2191-10-28**] 12:21PM BLOOD Hgb-11.7* calcHCT-35
[**2191-10-28**] 06:00PM BLOOD O2 Sat-94
[**2191-10-28**] 02:50PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.024
[**2191-10-28**] 02:50PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2191-10-28**] 02:50PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0
[**2191-10-28**] 02:50PM URINE CastGr-[**2-25**]*
URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000
ORGANISMS/ML.
Blood Culture, Routine (Pending):
.
CXR (Portable AP) [**2191-10-28**]:
FINDINGS: Single AP portable chest radiograph is obtained.
Evaluation is limited given the low lung volumes and obscuration
of the lung apices by patient's chin. There is marked elevation
of the left hemidiaphragm with associated collapse of the left
lower lobe. There is persistent aeration in the left upper lobe
definite signs of pneumonia. The patient's kyphotic position
also significantly limits the evaluation. The heart is shifted
into the right chest. Heart size cannot be assessed. Mediastinal
contour is also impossible to assess given the patient's
rotation and kyphotic position. No definite signs of pneumonia
in the right lung. No large effusions are seen. Bones appear
grossly intact.
IMPRESSION: Marked elevation of the left hemidiaphragm. Limited
study
Brief Hospital Course:
[**Age over 90 **]F no known prior lung disease presenting with respiratory
failure initially hypoxic then hypoxic/hypercapnic.
.
# Hypercarbic Respiratory Failure: Pt presented with hypercarbic
respiratory failure in setting of suspected PNA. CXR showed
right lower lobe and left upper lobe opacities concerning for
atelectasis vs. aspiration PNA. WBC increased from 11 on
admission to 17 the following day, though she remained afebrile.
She was started on broad coverage with zosyn and vancomycin
initially; azithromycin was then added for coverage of
atypicals. ABG showed severe respiratory acidosis
7.13/109/94/27. Oxygen saturations ranged from 80s to 90s; she
was kept on face tent as she was DNI/DNR on admission.
Discussion was held with family regarding poor prognosis and it
was decided that she be made [**Age over 90 3225**]. Antibiotics were discontinued
on HD2 and she was started on morphine drip as well as ativan
boluses for comfort. She passed at 18:35 on [**2191-10-29**]. Family
was notified and did not want a post-mortem.
.
# Septic shock: Pt remained severely hypotensive, with systolic
BPs as low as 60s. She was repeatedly bolused IV fluids with
minimal response. Family did not want a central line placed.
Given elevated WBC to 17 and suspected PNA, hypotension was
attributed to sepsis. UA was also found to be positive for
moderate leuks, >50 WBCs, and many bacteria. Urine culture
eventually grew >100,000 E.coli. She was treated for her PNA
with zosyn, vancomycin, and azithromycin. Antibiotics were
discontinued when family deemed pt [**Name (NI) 3225**] as prognosis was grim
given hypotension and respiratory failure.
.
# Hypothyroidism: She was maintained on her home dose of
levothyroxine IV rather than po as she was unable to tolerate
po.
Medications on Admission:
Buspar 10mg TID
remeron 15mg QHS
simvastatin 20mg QHS
lorazepam
synthroid 175mcg
prilosec 40mg daily
lactulose 15ml daily
calcium 600mg/Vit D
Ferrous sulfate
docusate
senna
MVI
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Urinary tract infection
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2191-10-29**]
ICD9 Codes: 5070, 0389, 5180, 5990, 2449, 311, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4751
} | Medical Text: Unit No: [**Numeric Identifier 68205**]
Admission Date: [**2129-7-23**]
Discharge Date: [**2129-8-3**]
Date of Birth: [**2129-7-23**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 68206**], twin
number one, was born at 31 and 6/7 weeks gestation, weighing
2060 grams. She was born to a 29 year-old, Gravida VII, Para
III now V mother, with prenatal screens as follows: Blood
type 0 positive, antibody negative, HBSAG negative, Rubella
non reactive, Rubella non immune, GBS unknown. The mother
has 2 older siblings that live with their father and she has
a 4 year old that lives with her. The father of this baby is
reportedly not involved and he is also the father of the 4
year old. Mother was transferred from [**Hospital3 3765**] on
the day prior to delivery for pregnancy induced hypertension.
She was treated with Magnesium sulfate, Ampicillin and
erythromycin. She received one dose of betamethasone 18 hours
prior to delivery. Rupture of membranes occurred prior to
delivery. Preterm labor developed. Contractions progressed
to full cervical dilatation with some cervical dilatation.
This infant delivered by Cesarean section due to vertex and
breech presentation of the twins. This infant emerged with a
vigorous cry, was given blow-by oxygen and had Apgars of 7
and 8 at 1 and 5 minutes.
PHYSICAL EXAMINATION: On admission, birth weight was 2060
which is 90th percentile. Length was 46 cm which is 75th to
90th percentile. Head circumference 30.5 cm which is 75th
percentile. Infant had mild to moderate respiratory
distress, was pink and well perfused in oxygen. Soft
anterior fontanel, normal facies, intact palate, mild to
moderate retractions, fair air entry. No murmur. Femoral
pulses were present. Flat and soft nontender abdomen without
hepatosplenomegaly. She had normal external genitalia,
stable hips and fair tone and active.
HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant had
mild to moderate respiratory distress on admission to the
NICU. She was placed on C-Pap and 21% FI02. While on C-Pap,
initial gases were stable. She weaned from C-Pap to room air
on day of life one, within the first 24 hours. She has
remained on room air since that time. She has not received
any methylxanthine therapy, although she does have
approximately 1 to 2 spells per day which are mild and
usually self-resolved. Her respiratory rates at present are
30s to 50s with stable oxygen saturations greater than or
equal to 95% on room air.
Cardiovascular: She has remained hemodynamically stable. She
has had no murmurs audible. Normal heart rate, blood
pressure and perfusion. No cardiovascular issues at this
time.
Fluids, electrolytes and nutrition: IV fluids were initiated
on admission to the NICU. She remained n.p.o. until day of
life one when enteral feedings were started and she began a
slow advance in feeds and achieved full feeding by day of
life 5 which is [**2129-7-28**]. Her calories were concentrated to a
maximum caloric density of 26 calories per ounce of either
breast milk, using HMF 4 calories per ounce and 2 calories
per ounce of MCT oil or Special Care 24 with an additional 2
calories per ounce of MCT oil, at 150 ml/kg/day pg q. 4
hours. Her most recent set of electrolytes was on [**2129-7-26**]
with a sodium of 141, potassium of 5.7 which was hemolyzed,
chloride of 112 and a C02 of 18. Her most recent weight is
2180g.
Gastrointestinal: She presented with a peak bilirubin level
of 9.7 over 0.3 on day of life 3, [**2129-7-26**]. Phototherapy was
initiated at that time. She received a total of 2 days of
phototherapy and had a most recent bilirubin level of 4.7
over 0.2 on [**2129-7-31**] which was declining from a rebound
bilirubin level.
Hematology: Hematocrit on admission was 45; platelet count
of 273. Those were the only hematocrit and platelets
measured. She has had no issues requiring blood product
transfusion and is pink and well perfused. Blood typing has
not been done on this infant.
Infectious disease: CBC and blood culture were screened on
admission due to the preterm labor. The CBC was benign. She
received 48 hours of Ampicillin and Gentamicin which was
subsequently discontinued when the blood pressure remained
negative at 48 hours. She has had no further issues with
sepsis.
Neurology: Head ultrasound was screened on [**2129-7-28**] which is
day of life 5 which showed normal cranial ultrasound. She has
maintained a normal neurologic exam throughout her stay in
the NICU.
Sensory:
Audiology: Hearing screens were not done so far but will
need to be done prior to discharge home.
Ophthalmology: No eye exams have been performed thus far.
The patient will be due for the first eye examination in
approximately 2 weeks.
Psychosocial: A [**Hospital1 18**] social worker has been involved with
this family. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**].
She can be reached at [**Telephone/Fax (1) 8717**] if there are any concerns.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 3765**] nursery,
level II.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], telephone
number [**Telephone/Fax (1) 64482**].
CARE RECOMMENDATIONS:
Feeds of 26 calorie breast milk or Special Care at 150 ml/kg/day
pg.
Medications: None.
Car seat screening should be done prior to discharge from the
hospital.
Will require repeat state screen on [**8-6**].
IMMUNIZATIONS RECEIVED: None thus far.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 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.
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.
State newborn screen was sent on day of life 3. Results are
pending. This should be repeat on [**8-6**].
DISCHARGE DIAGNOSES:
1. Respiratory distress resolved.
2. Sepsis ruled out.
3. Hyperbilirubinemia resolving.
4. Apnea of prematurity ongoing.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2129-8-2**] 18:50:48
T: [**2129-8-2**] 19:18:55
Job#: [**Job Number 68207**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4752
} | Medical Text: Admission Date: [**2155-5-19**] Discharge Date: [**2155-5-21**]
Date of Birth: [**2108-2-27**] Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
hemoperitoneum
Major Surgical or Invasive Procedure:
-diagnostic paracentesis
-IR embolization of hepatic artery branch
-exploratory laparotomy with multiple liver biopsies
History of Present Illness:
47 year old male with history of EtOH cirrhosis transferred from
[**Hospital3 26615**] Hospital for hypotension
and bloody ascites. Patient states that he has liver cirrhosis
[**12-18**] ETOH for approximately 10 yrs. In
the past year, patient developed ascites and received
paracentesis 3 times. In the past few days, patient has been
experiencing increasing abdominal distention, nausea without
vomiting. He presented to [**Hospital3 26615**] Hospital where he was
found to be hypotensive. 250ml of NS bolus was given and a
paracentesis
was performed. There was immediate return of blood during the
procedure. Transfusion was initiated, patient had a CT scan of
A/P and he was transferred to [**Hospital1 18**]. On arrival, he was
hypotensive with SBP in 80-90's and HR in 100s. He complained of
abdominal distention, diffuse pain and some shortness of breath.
Past Medical History:
PMHx:
- Hepatic cirrhosis [**12-18**] ETOH with ascites
- HTN
- Anxiety/Depression
- Seizure
PSHx:
- L5 surgery
- Open cholecystectomy
- head injury repair
Social History:
SHx:
- [**2-18**] cig/day
- [**12-19**] 6-pack ETOH/day, quit in [**2-/2155**]
- No reported hx IVDU
Family History:
Non-contributory
Physical Exam:
Vitals: 96.4 101 92/50 16 100%
Gen: lethargic but arousal, A&Ox3
HEENT: NC/AT, on LAD, dry mucosa, +icterus
Chest: b/l breath sounds clear anterior
CV: sinus tach, S1S2
Abd: distended, minimal tenderness, soft, +fluid wave
Ex: no edema, no cyanosis, palp distal pulses
Pertinent Results:
Admission Labs:
WBC-16.4* RBC-2.53* Hgb-7.6* Hct-25.3* MCV-100* MCH-30.1
MCHC-30.1* RDW-17.8* Plt Ct-124*
PT-22.6* PTT-77.5* INR(PT)-2.1*
Glucose-249* UreaN-39* Creat-3.4* Na-129* K-5.5* Cl-89* HCO3-<5
ALT-1544* AST-6156* AlkPhos-318* TotBili-3.1*
Calcium-7.7* Phos-13.5* Mg-2.4
Lactate-20.9* K-5.2
AFP 1870
Brief Hospital Course:
Mr. [**Known lastname 27985**] was transferred to [**Hospital1 18**] with a massive
intra-abdominal hemorrhage. He was aggressively resuscitated
with blood products and cyrstalloids, and developed a pressor
requirement. Due to his increasingly severe condition, he was
intubated in the ED. Upon review of the CT scan obtained at the
outside hospital, it was unclear if he was bleeding from a varix
or from his liver. A diagnostic paracentesis was performed in
the ED, which returned frank blood. It was felt that this was
more likely bleeding from his liver, and he was brought to
interventional radiology for angiography and embolization. No
definite source was identified in angiography. After discussion
with his family, we elected to take him to the operating room
for emergent exploratory laparotomy in the early morning of HD
2. Upon entering his abdomen, approximately 8L of bloody
ascites were immediately drained. A thorough examination of his
abdomen was undertaken, which revealed a very nodular, cirrhotic
liver, with multiple large masses, which were biopsied. No
active bleeding was identified at the time of operation. His
abdomen was closed and a drain left in place. He received 3L
IVF, 2u red cells, 2u FFP, and 2u cryo in the OR. He was
brought to the ICU with a continued pressor requirement. Over
the course of POD 0, he continued to require pressor support and
blood products, and received 5u PRBC's, 2u platelets, 7u FFP,
and 1u cryoprecipitate, without an appropriate increase in his
laboratory values. His JP drain continued to have high-output
bloody ascites. A CT of his abdomen was obtained, which
demonstrated re-accumulation of large hemoperitoneum, new bowel
wall thickening in the ascending colon, thrombosis of left main
portal vein, hyperenhancement of bilateral kidneys c/w ATN, and
multiple hyperdensities within the spleen c/w infarction. A
family meeting was held the evening of HD 2/POD 0, at which time
they elected to make him CMO. He was extubated in the late
evening of HD 2, and expired at 0333am on [**2155-5-21**]. The family
declined an autopsy.
Medications on Admission:
Ambien 10mg qhs, Clonazepam 1", Lasix 40', Spironolactone 100',
Omeprozole 20', Vit K 5', Gabapentin 100''', Ibuprofen prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Massive intra-abdominal hemorrhage
Death
Discharge Condition:
Expired
Completed by:[**2155-5-21**]
ICD9 Codes: 5845, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4753
} | Medical Text: Admission Date: [**2121-3-17**] Discharge Date: [**2121-3-19**]
Date of Birth: [**2039-3-20**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
81 y.o. male with history of colonic adenomatous polyp and grade
2 esophagitis in [**2118**] who presents with a chief complaint of
hematochezia x 1 day. Patient reports up to 6 grossly bloody,
loose BMs with ? melena and diaphoresis, but no hematemesis,
abdominal pain, fevers/chills, N/V, lightheadedness, CP, SOB,
palpitations. Given the ongoing symptoms, patient presented to
the ED for further evaluation.
.
In the [**Hospital1 18**] ED, vitals were: T - 97.4, BP - 111/57, HR - 90, RR
- 18, O2 - 99% RA. Hct was 26.7, down from 36.3 in in [**8-3**]. NGL
was negative, however, there was no bilious return. Though
patient was hemodynamically stable, he was admitted to the ICU
for close observation and GI follow-up.
Past Medical History:
Hypertension
Chronic Renal Insufficiency (baseline of 1.8 - 2)
CML
Gout
Chronic Low Back Pain
Carpal Tunnel Syndrome
BPH
Social History:
Patient denies tobacco or illicit drug use. He reports
occasional alcohol consumption. He is a tax attorney, married.
Family History:
NC
Physical Exam:
Vitals: T - 97.2, BP - 124/65, HR - 78, RR - 18, O2 - 95% RA
General: Awake, alert, NAD, resting comfortably in bed
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, no LAD
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB
Abd: Soft, NT, ND, + BS
Rectal: Guaiac positive, maroon colored stool
Ext: No c/c/e
Neuro: Grossly intact
Skin: No lesions
Pertinent Results:
[**2121-3-16**] 11:50PM BLOOD WBC-15.7* RBC-2.52* Hgb-9.1*# Hct-26.7*#
MCV-106* MCH-36.3* MCHC-34.2 RDW-18.1* Plt Ct-484*
[**2121-3-16**] 11:50PM BLOOD Glucose-208* UreaN-39* Creat-2.4* Na-140
K-6.2* Cl-107 HCO3-21* AnGap-18
[**2121-3-17**] 06:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
Brief Hospital Course:
81 y.o. male with history of colonic polyps and esophagitis who
presented with hematochezia.
.
# Hematochezia: Pt presented with hematochezia and hct of 26.7.
Had a h/o diverticulosis and polyps which could have been the
source of the bleed. Patient intially admitted to the MICU. Hct
slowly trended down and pt initially reluctant to get
transfusions, but eventually agreed. Was prepped and had
colonoscopy that showed diverticulosis of the entier colon,
irregular site of previous polypectomy and otherwise nl
colonoscopy to cecum. Prep was noted to be poor. He was
hemodynamically stable, with stable hct and called out to the
floor. He then underwent an EGD, which showed a single
superficial non-bleeding 5mm ulcer was found on the posterior
wall of the antrum. No blood was found in the upper tract, and
the ulcer showed no stigmata of bleeding. This lesion is an
unlikely cause of hematochezia. It seems probably that the
event that precipitated this admission was a diverticular bleed.
As his colonoscopy prep was poor, and he had a previous polyp,
he should return for an elective colonoscopy sometime later this
year. With his previous history of esophagitis and the current
finding of an ulcer, it may be most prudent to continue acid
reduction therapy indefinitely.
.
# Chronic Renal Insufficiency: Increased at admit at 2.4 from
baseline of 1.8 - 2, possibly due to hypovolemia from GIB.
Improved with fluids and transfusions to baseline.
.
# Leukocytosis/Thrombocytosis: No localizing symptoms or
evidence of infection. UA was negative. Patient does have
myeloproliferative disease and WBC has been elevated in the
past, though more recently was normal. He was monitored for
fevers and remained afebrile.
.
# CML: No active issues> he was continued on hydrea
.
# Gout: He was continued on renally dosed allopurinol.
.
# BPH; Alpha blockers held in the setting of GIB
.
# Chronic Pain: He received Tylenol PRN andLow-dose narcotics
PRN for continued pain as BP tolerated
.
# Code status: FULL
Medications on Admission:
Allopurinol
Finasteride
Hydrea
Ambien
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diverticular Bleed
Secondary Dx:
Acute Renal Failure
Chronic renal insufficiency
Myeloproliferative disease
Gout
BPH
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission for
gastrointestinal bleed. You required blood transfusion, and RBC
count has since held stable. Colonoscopy yesterday was normal.
Today's upper endoscopy today found a single superficial
non-bleeding 5mm ulcer. No blood was found in the upper tract,
and the ulcer showed no stigmata of bleeding. This lesion is an
unlikely cause of your bleeding. It seems probably that the
event that precipitated this admission was a diverticular bleed.
Your colonoscopy prep was poor, and he as you had a previous
polyp, you should return for an elective colonoscopy sometime
later this year.
With a previous history of esophagitis and the current
finding of an ulcer, it may be most prudent to continue acid
reduction therapy indefinitely.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **] [**3-26**] at 130pm
You have a repeat colonoscopy set up for [**5-1**] at 8am Please call
([**Telephone/Fax (1) 2233**] with questions. Information will be mailed to
you in the mail.
ICD9 Codes: 5849, 2851, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4754
} | Medical Text: Admission Date: [**2194-10-9**] Discharge Date: [**2194-10-29**]
Date of Birth: [**2145-3-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Effexor
Attending:[**First Name3 (LF) 7015**]
Chief Complaint:
Diarrhea for 3 weeks
Major Surgical or Invasive Procedure:
PICC line insertion, lumbar puncture attempt
History of Present Illness:
49 y/o female with a history of seizure disorder, NIDDM,
hypertension, alcohol abuse, presenting with persistent
non-bloody diarrhea and dehydration for the past 10 days.
Patient reports that she was visiting [**Doctor First Name 5256**], ate steak
a ta Cracker [**Last Name (un) 7016**], and then began to have severe nausea,
vomiting, and diarrhea. She reports associated chills, and
overall weakness. She presented to Duke with these symptoms and
and was admitted for IVF hydration with negative blood and stool
cultures per the husband's report. Since returning, her symptoms
have persisted and worsened to now 10 watery bowel movements per
day. Yesterday, she presented to her PCP's office with continued
diarrhea, vomiting any PO intake, tachycardia, and weak BP, and
it was recommended she go to the ED. She deferred until this
morning as she felt worse today.
.
In the ED, initial vs were: T 97 P 110 BP 86/47 R 18 O2 sat 100%
RA. Patient bolused 2 L NS with improvement in SBP to 115. K was
found to be 2.6, mg was 1.6, both repleted. CXR was normal. ECG
showed subtle flattenning of T waves in V2-V6, and patient was
given asp 325.
.
On the floor, patient's initial vitals T 96.2 HR 100 BP 110/62
RR 16 96% RA. She was somewhat drowsy on interaction; however,
stated she feels better after the IVFs.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias or skin changes.
Past Medical History:
Seizures
Diabetes mellitus
Hypertension
Schizophrenia
Alcohol abuse
Hepatitis C
Social History:
She lives at home with her husband. She quit working 15 years
ago, but was previously in sales and an administrator at a
construction company. She quit smoking cigarettes 3 months ago,
but previously smoked 1 ppd x >30 years. She has not had any
EtOH in 6 months, but has a history of EtOH abuse. She denies a
history of drug abuse, but per prior socialhistories there is a
history of cocaine abuse in the past.
Family History:
Her maternal uncle had seizures.
Physical Exam:
ADMISSION PHYSCIAL EXAM
Vitals: T 96.2 HR 100 BP 110/62 RR 16 96% RA
General: Patient drowsy and somewhat somnolent, oriented x 3, no
acute distress
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Distended, somewhat firm, tender to deep palpation
diffusely, hyperactive bowel sounds
Ext: 2+ pulses, no clubbing, cyanosis or edema
Skin: No rashes, bruises noted
Neuro: Alert + Oriented x 3, appropriate affect
DISCHARGE PHYSICAL EXAM
Vitals: T 98.1 HR 85 BP 100/53 RR 20 100 RA
General: Patient was comfortable in NAD, AAOx3
Abd: soft, nontender, slightly distended
Ext: trace edema, no clubbing or cyanosis
Pertinent Results:
ADMISSION LABS:
.
[**2194-10-9**] 10:30AM BLOOD WBC-10.9 RBC-4.74 Hgb-12.0 Hct-37.3
MCV-79* MCH-25.4* MCHC-32.2 RDW-19.6* Plt Ct-341#
[**2194-10-9**] 10:30AM BLOOD Glucose-242* UreaN-29* Creat-1.4* Na-130*
K-2.6* Cl-97 HCO3-17* AnGap-19
[**2194-10-12**] 01:20PM BLOOD ALT-11 AST-24 LD(LDH)-461* AlkPhos-106*
TotBili-0.1
[**2194-10-9**] 10:30AM BLOOD cTropnT-<0.01
[**2194-10-9**] 10:30AM BLOOD Calcium-8.2* Phos-4.8* Mg-1.6
[**2194-10-12**] 01:20PM BLOOD Valproa-81
[**2194-10-12**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2194-10-9**] 10:37AM BLOOD Lactate-2.0
.
ECG [**10-9**]: Sinus tachycardia. There are small R waves in the
anterior leads consistent with possible prior anterior
myocardial infarction. Non-specific ST-T wave changes. Compared
to the previous tracing ST-T wave changes are new.
.
EEG [**10-12**]:
CONTINUOUS EEG: The background was slightly slow reaching a
maximum of
7 Hz. There were no clear epileptiform discharges or
electrographic
seizures noted.
SPIKE DETECTION PROGRAMS: There were 91 entries in these files.
These
represented electrical and muscle artifact.
SEIZURE DETECTION PROGRAMS: There were three entries in these
files.
These represented electrical and movement artifact.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: There was no clear sleep architecture noted in the
record.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 90 bpm.
IMPRESSION: This is an abnormal video EEG telemetry due to the
presence
of a slow background which reached a maximum of 7 Hz. This
represents a
mild encephalopathy such as can be seen in toxic/metabolic,
diffuse
ischemic, or infectious etiologies. There were no clear
epileptiform
discharges or electrographic seizures noted.
.
EEG [**10-13**]:
CONTINUOUS EEG: The background was slow reaching a maximum of
5.5 Hz.
Of note, from 15:23 onward, the patient is not being recorded,
as the
leads appear to be off.
SPIKE DETECTION PROGRAMS: There were no entries in these files.
SEIZURE DETECTION PROGRAMS: There were no entries in these
files.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: There was no clear sleep architecture noted in the
record.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 100 bpm.
IMPRESSION: This is an abnormal video EEG telemetry due to the
presence
of a slow background which reached a maximum of 5.5 Hz. This
represents
a moderate to severe encephalopathy such as can be seen in
diffuse
ischemia, toxic/metabolic, infectious, or other diffuse
etiologies.
Note is made of lack of readable recordings after 15:23. There
were no
clear epileptiform discharges or electrographic seizures noted.
.
[**10-13**] CT HEAD W/O CONTRAST:
IMPRESSION: No evidence of definite acute abnormalities. The
apparent thin
left parietal extraaxial hyperdensity is likely an artifact, but
could be
reassessed by a follow-up CT or by MRI.
.
MR HEAD [**10-14**]:
FINDINGS:
There is considerable motion artifact degrading image quality.
The gradient echo images are nondiagnostic. There is no
intracranial mass, mass effect or abnormal enhancement. No acute
infarct is demonstrated. The ventricular dimensions and sulcal
prominence are advanced for age.
IMPRESSION:
No evidence of intracranial mass, acute infarct or abnormal
enhancement.
Gradient echo images are degraded by motion artifact. Mild
degree of
generalised cerebral atrophy advanced for age.
.
CXR [**10-14**]:
FINDINGS: In comparison with the study of [**9-12**] and [**9-11**], there
is some
continued opacification in the retrocardiac region medially,
concerning for pneumonia. The right PICC line now extends to the
region of the mid portion of the SVC.
.
CXR [**10-16**]:
Cardiac size is top normal. Right PICC tip is in the mid SVC in
unchanged
position. Retrocardiac opacity has improved consistent with
improving
atelectases. The right lower lobe opacity consistent with
atelectases is
unchanged. There is no pneumothorax or pleural effusion.
.
EGD/COLONOSCOPY BIOPSIES:
Intestinal mucosal biopsies, three:
A. Duodenum:
Chronic active duodenitis with prominent increase in
subepithelial collagen, surface epithelial damage, and subtotal
villous shortening, see note.
B. Terminal ileum:
Small intestinal mucosa with largely denuded epithelium and
increased subepithelial collagen, see note.
C. Random colon:
1. Colonic mucosa with increased lamina propria chronic
inflammation, surface epithelial damage, and increased
intraepithelial lymphocytes, see note.
2. No appreciable increase in subepithelial collagen noted on
H&E stained sections.
Note: In evaluable epithelium in the duodenal and terminal ileal
biopsies, there is additionally a prominent increase in
intraepithelial lymphocytes. The findings are consistent with a
collagenous enteritis with concurrent microscopic (lymphocytic)
colitis. These entities are known to co-exist in a rare
subgroup of patients and show marked clinical response to
steroid therapy. No microorganisms or viral cytopathic effect
are seen. Special stains to rule out possible co-existing
infection and to confirm the presence of increased subepithelial
collagen will be reported in an addendum. Preliminary findings
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2194-10-22**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**].
ADDENDUM # 1:
Trichrome stain highlights a diffuse, markedly increased
subepithelial collagen layer thickness in both the duodenal and
ileal mucosal biopsies, while showing a patchy increase in the
colonic mucosal biopsies. This supports a diagnosis of
collagenous enterocolitis.
[**Country 7018**] Red stain is negative for amyloid deposition in the
duodenal biopsy with satisfactory control.
Giemsa stain reveals no microorganisms in the small intestinal
biopsies with satisfactory control.
Brief Hospital Course:
49 y/o female with a history of seizure disorder, IDDM,
hypertension, alcohol abuse, initially presented with
persistent, profuse, non-bloody diarrhea, biopsies consistent
with collagenous colitis, course complicated by ICU transfer for
unresponsiveness and altered mental status, likely a post-ictal
state from subclinical seizure.
.
#. Collagenous enterocolitis: Initially, etiology of patient's
diarrhea was thought to be infectious and stool studies
indicated a secretory process. She was started on cipro/flagyl
and supported with IVFs for dehydration and electrolyte
repletion as needed. Initial stool studies were negative for
infection and C. diff, and stool study results were obtained
from Duke, which were also negative. Her diarrhea continued to
be profuse, about 4-5 L/day. Ciprofloxacin was discontinued
during her ICU course due to increase risk of seziures (see
below). C. diff PCR and toxin were negative, although patient
was continued on flagyl. GI was consulted, and recommended
exploring other etiologies of secretory diarrhea, including
sending tests for neuroendocrine tumors. (These tests were
pending at the time of discharge). EGD and colonoscopy was
performed and showed no evidence of pseudomembranous colitis,
thus flagyl was discontinued. Biopsies showed findings
consistent with microscopic colitis, and stains conformed the
diagnosis of collagenous colitis. Patient was started on
budesonide 9 mg per day on [**10-22**] andwill continue until her
appointment with Gastroenterology. Patient's diarrhea began to
decrease with the help of Lomotil qid.
.
#. Altered mental status/Seizure: Patient has a history of
seziures controlled on Depakote 1000 mg [**Hospital1 **]; she had not been
taking this med several days prior to admission due to poor PO
intake. Patient's mental status began to change on hospital day
#4. She became increasingly somnolent, was unresponsive. Labs
showed a worsening NAG acidosis and an ABG showed 7.33/23/100
with lactate of 1.1. She had no meningeal signs, was afebrile,
serum tox negative. Due to her history of seziures, and the
fact that she had been off her PO depakote, neurology
recommended giving 1 mg ativan to treat possible seizure. She
subsequently became more somnolent and was transferred to the
MICU. In the ICU, 24 hour EEG only showed slow-wave activity,
consistent with toxic/metabolic encephalopathy or post-ictal
state. Head CT and MRI were both negative. Vanc/Ceftriaxone and
acyclovir were started for emperic coverage of CNS infection.
LP was attempted but unsuccessful x 3. Patient was transferred
abck to the floor stable, but still somnolent. Acyclovir was
discontinued as viral encephalitis was unlikely.
Vanc/Ceftriaxone was continued for treatment of
hospital-acquired pneumonia (see below). Her mental status
began to clear and patient became more responsive over the next
several days. She was maintained on IV Depakote and dose was
adjusted based on trough levels. Once she able to tolerate POs,
she was transitioned to PO Depakote at home dose without
complications. She will have her valproate levels checked on
[**10-31**] with results faxed to Dr. [**First Name (STitle) **]. Her altered
mental status was likely due to a prolonged post-ictal state
after a subclinical seizure secondary to patient being off
depakote for several days. By discharge, her mental status had
cleared and she was interative and back to her baseline.
.
#. Nutritional status: Patient's albumin prior to discharge was
1.7, likely secondary to poor intake. The low albumin also
caused diffuse edema and thrid spacing from massive IVF
hydration over the past several weeks, which made the patient
uncomfortable. Nutrition was consulted and recommended that
patient drink supplemetal formulas along with full PO diet to
increase protein intake to ultimately raise the albumin. As per
GI she should be on a gluten free diet.
.
#. Schizophrenia: On admission, patient had not been taking
clozapine for several days. Her dose was held through most of
her admission as she was not able to tolerate POs. Psych
recommended starting at 12.5 mg once a day and slowly titrating
up to patient's home dose. One 12.5 mg dose was administered;
however, the patient became orthostatic, and subsequent doses
were held. Her clozaril was held prior to discharge and will
discuss restarting during her follow up appointment with [**First Name8 (NamePattern2) 7019**]
[**Last Name (NamePattern1) **].
.
#. Hypertension: Lisinopril was held during patient's admission
due to dehydration and labile blood pressures. She should
discuss restarting lisinopril during her primary care
appointment.
.
#. IDDM: Patinet's lantus was halved to 5 units qhs as she was
not tolerating POs and sugars were maintained on an ISS during
admission.
Medications on Admission:
Omeprazole 20 mg Cap, Delayed Release 1 Capsule(s) by mouth
daily Divalproex 500 mg Tab, Delayed Release 2 Tablet(s) by
mouth twice daily
Clozapine 100 mg Tab 3 Tablet(s) by mouth daily at bedtime
Multivitamin Tab 1 Tablet(s) by mouth daily
Folic Acid 1 mg Tab 1 Tablet(s) by mouth daily
Lantus 100 unit/mL SubQ Cartridge Subcutaneous 16-18 units
Cartridge(s) q pm
glipizide 5 mg Tab Oral 1 Tablet(s) Once Daily, in am
Lomotil 2.5 mg-0.025 mg Tab Oral 1 Tablet(s) , as needed
lisinopril 5 mg Tab Oral 1 Tablet(s) Once Daily
Vitamin B-1 100 mg Tab Oral 1 Tablet(s) Once Daily
Discharge Medications:
1. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Lantus 100 unit/mL Cartridge Sig: 16-18 UNITS Subcutaneous at
bedtime.
5. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Outpatient Lab Work
Please check valproate level and fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(Phone: [**Telephone/Fax (1) 3294**], Fax: [**Telephone/Fax (1) 7020**]).
7. budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
8. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please check CBC have results faxed to [**Last Name (LF) 7021**],[**First Name3 (LF) **] L
[**Telephone/Fax (1) 7022**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Microscopic colitis
Hypotension
Seizure disorder
Seconadary:
Schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of persistent diarrhea.
This diarrhea was found to be due to an autoimmune process
called microscopic colitis. This condition is treated with the
steroid budesonide which you will continue until your appoinment
on [**11-27**]. You will be followed by the gastrointestinal
doctors for this condition.
You were also noted to have low blood pressures. This was most
likley due to all the fluid you were losing with the diarrhea.
Your lisinopril was held and should continue to be held. You
should discuss restarting this medication with your primary care
doctor. You should have your blood count checked on [**10-31**] when
you have your valproate level checked.
Your clozapine was also held because of the concern that it was
lowering your blood opressure further. You should discuss
restarting when you meet with [**First Name8 (NamePattern2) 7019**] [**Last Name (NamePattern1) **] on [**11-5**].
The Neurologists visited you during your admission. You will
have a follow up appointment with Dr. [**First Name (STitle) **]. you will have your
valproate levels checked [**10-31**] and the results will be sent to
Dr. [**First Name (STitle) **].
You should start a gluten free diet after you are discharged.
This was recommended by your gastroenterologists to prevents
worsening diarrhea.
Medications Changes During This Admission
Hold Lisinopril
Hold Clozapine
Continue Budesonide
Continue Lomotil (stop when your diarrhea stops)
Followup Instructions:
GASTROINTESTINAL:
Thursday [**11-27**] @ 8:20 AM with Dr. [**Last Name (STitle) **]
[**Location (un) 453**] [**Hospital Unit Name 1825**]
Name: [**Last Name (LF) 7021**],[**First Name3 (LF) **] L.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Appointment: Monday, [**11-10**] at 4:15PM
Name: [**Male First Name (un) **], [**Doctor First Name 7019**]
Specialty: Psychiatry
Location: [**Last Name (NamePattern1) 5805**] [**Location (un) 538**], [**Numeric Identifier 7023**]
Phone:[**Telephone/Fax (1) 7024**]
Appointment: Wednesday, [**11-5**] at 11:30AM
Department: NEUROLOGY
When: TUESDAY [**2194-11-18**] at 7:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Nutrition Services
Phone: ([**Telephone/Fax (1) 7026**]
Appt: Please contact Nutrition Services directly to set up
nutrition counseling. Discuss your doctors [**Name5 (PTitle) 7027**] of a
gluten free diet.
ICD9 Codes: 5849, 486, 2761, 4589, 2859, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4755
} | Medical Text: [** **] Date: [**2164-2-2**] Discharge Date: [**2164-2-7**]
Date of Birth: [**2108-8-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / erythromycin (bulk) / Compazine / Bactrim DS /
Sulfa (Sulfonamide Antibiotics) / Dapsone / Levaquin /
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Left ear pain and hearing loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung
disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 10%,
adriamycin toxicity), Factor V Leiden, s/p trach and PEG
placement, here with recurrent fevers. She was admitted to [**Hospital1 18**]
last year for respiratory distress was intubated and unable to
wean off the [**Last Name (un) **]. She then got a trach and PEG tube. Her
hospitalization was complicated by pna, recurrent fevers, and
C.diff. She was then discharge to [**Hospital 100**] rehab. In [**Month (only) **] she was
transferred to [**Hospital3 105**] for continued [**Hospital3 **] weaning. She
has had a complicated course since then w/ pneumomediastinum, R
pneumothorax with CT placement in [**Month (only) **], worsening CHF with EF
decreased from 30% to 10%, [**Last Name (un) **] requiring temporary HD, anemia of
chronic disease requiring blood transfusions (last on [**1-31**] for
Hct of 25). Recurrent C-diff with extended course of flagyl and
vanco and resistant pseudomonas pna most recently + sputum cult
on [**1-30**] for which pt was being treated with colistimethate and
aztreonam.
.
Pt was being weaned off the [**Month/Year (2) **] with 20hours off the [**Month/Year (2) **] on
trach mask and only requiring 4 hours of [**Month/Year (2) **] support. However,
in the last 2 days, she was only able to tolerate respiratory
trial off the [**Month/Year (2) **] for most of 1.5 hours. She had increased
sputum and became febrile to 102. She also c/o increase L ear
pain and decrease hearing. She had a CT scan of maxillofacial
sinuses from [**1-30**] that showed mastoiditis and otitis media. As
per note, there was concern for cholesteatoma and she was
transfer here for ENT eval.
.
On arrival to the ED, her initial vitals were Temp of 97.6, 115,
99/75, 30, 100% on trach on [**Month/Year (2) **]. Patient was given vanc and
cefepime and receiced 2L of NS. Her BP responded by increasing
to 110s/60s. She has reamined sinus tachy in 110s. She had a
femoral line placed which the patient was pulled as per nursing
report. She had some of of the fluid and vanco infiltrated into
her tight. Her CT of her maxillofacial sinuses in OHS was
evaluated by our radiologist and the prelim reports that there
is no new findings when compared to prior CT done in [**Month (only) **].
.
On arrival to the MICU, pt is on [**Month (only) **] via trach with pressure
control Fio2 35%, PEEP 5, PIP 35, rate of 14 sating 100%. Pt is
overall comfortable. She is sleepy, but responsive. Answering
appropriately to questions. She had just received some ativan
prior to my evaluation.
.
Review of systems: Unable to fully assess ROM given that she is
non-verbal due to trach and sleepy on arrival.
(+) Per HPI. She c/o increase L side ear pain and decrease
hearing on L side, mild L facial edema as per OHS note. Occ
diarrhea
Past Medical History:
- s/p trach/PEG [**9-1**]
-Sarcoidosis: treatment History: methotrexate [**12-31**], stopped [**1-31**]
due to reaction, prednisone 10-20-10-7.5mg [**Date range (1) 107077**] stopped due
to Cushingoid side effects in [**10-31**].
- Non-Hodgkin's lymphoma (27 years ago) s/p chemotherapy c/b
bleo lung tox, autologous BMT, and high-dose myeloablative total
body irradiation.
- Pulmonary embolism with Factor-5 Leiden- long term coumadin
goal INR [**1-26**] therapy
- Status post CVA with memory deficit.
- Stage III-IV chronic kidney disease.
- Systolic CHF- [**1-25**] adriamycin from large cell lymphoma several
years ago. Recent Echo 30%.
- Hypertension.
- Hyperlipidemia
- Mild sleep apnea.
- Anxiety
- Gout.
- Anemia - on Aranesp
- Iron overload.
- Multiple environmental allergies
Social History:
Currently living at [**Hospital 100**] Rehab x2 weeks. She has been on
disability for the past 15 years, but used to work in a hotel as
a reservations consultant.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
- Maternal: clots, PE, TIA, Factor V Leiden, dementia at 92
- Paternal: CAD, pancreatic CA
- Siblings: sister died [**2162-12-24**] from complications of DM,
another sister with thyroid problems and high cholesterol
- Children: one healthy daughter without [**Name2 (NI) **] V Leiden
- Uncle: colon cancer
Physical Exam:
Vitals: 115, 129/77, RR 26, 100% on [**Name2 (NI) **]
General: sleepy but responsive to verbal stimuli. Non-verbal due
to trach, but answering appropriately to questions. No acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, Mild left facial edema and non tender L ear or
mastoid process. L tympanic membrane with yellowish opacity,
bulging. R with pearl white membrane.
Lungs: rhochorus through out, no increase in WOB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present (hyperactive), no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses on bil LE, no clubbing,
cyanosis or edema.
Pertinent Results:
Head CT [**2-2**]: FINDINGS: There is complete opacification of the
left mastoid air cells and the left middle ear. This is similar
in appearance to the [**2163-9-16**] study. There is no
underlying bony destruction. Opacification of the left mastoid
air cells are seen as far back as [**2162-11-21**]. Remaining
visualized paranasal sinuses and right mastoid air cells are
clear.
.
IMPRESSION: Chronic opacification of the left mastoid air cells
and left
middle ear with no evidence of underlying bony destruction.
.
Chest X-Ray [**2-2**]: IMPRESSION: Overall, there is slight increased
opacity of the interstitial markings and ultimately it is
difficult to determine whether there is a superimposed process
on the extensive background of abnormal lungs. Consider, if
clinically feasible, a trial of diuresis with repeat radiography
to discern whether there is an element of superimposed pulmonary
edema.
.
[**2164-2-2**] 10:20PM BLOOD WBC-16.5*# RBC-3.31* Hgb-10.6* Hct-32.2*#
MCV-97 MCH-32.1* MCHC-33.0 RDW-19.8* Plt Ct-209#
[**2164-2-7**] 03:51AM BLOOD WBC-12.1* RBC-2.91* Hgb-9.6* Hct-29.3*
MCV-101* MCH-32.9* MCHC-32.8 RDW-18.9* Plt Ct-266
[**2164-2-4**] 06:05AM BLOOD Neuts-54 Bands-4 Lymphs-12* Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-13*
[**2164-2-2**] 10:20PM BLOOD Glucose-66* UreaN-29* Creat-1.3* Na-135
K-5.2* Cl-98 HCO3-29 AnGap-13
[**2164-2-7**] 03:51AM BLOOD Glucose-117* UreaN-61* Creat-1.4* Na-141
K-4.0 Cl-108 HCO3-25 AnGap-12
[**2164-2-3**] 03:57AM BLOOD Cortsol-7.9
[**2164-2-6**] 06:30AM BLOOD Vanco-18.3
[**2164-2-2**] 10:30PM BLOOD Lactate-1.1
Brief Hospital Course:
Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung
disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 10%,
adriamycin toxicity), Factor V Leiden, s/p trach and PEG
placement who was sent from [**Hospital3 **] due to concern for
mastoiditis. Also noted to have fevers and being treated for
pseudomonal pneumonia.
.
# ? Mastoiditis: The OSH was concerned for possible infection
and sent her to [**Hospital1 18**] for ENT evaluation. After review by our
radiologist, there was no significant change in the CT scan when
compared to in [**Month (only) 359**]. Seen by ENT- felt no clinical or
radiological evidence of acute mastoiditis, and fluid likely
chronic. No clear evidence of cholesteotoma on CT scans. They
recommend outpatient follow up with Dr. [**Last Name (STitle) 3878**] [**Telephone/Fax (1) 2349**].
She was briefly started on IV vancomycin which was discontinued
prior to discharge.
.
#. Fevers: On her last [**Telephone/Fax (1) **] in [**Month (only) 359**] she presented with
fevers which were not thought to be due to infection. She was
started on Vanc and meropenam however they were discontinued
prior to discharge. She presents now with a leukocytosis and
increased difficulty weaning off [**Month (only) **] concerning for a pulmonary
process. She was recently found to have pseudomonas growing in
her sputum on [**2164-1-30**] (2 strains that were multi-drug resistant
that was sensitive to amikacin. However there has been state
shortage of Amikacin and he was started on colistimethate and
had aztreonam added on [**2164-1-30**]). She was on aztreonam and
colistin upon [**Date Range **]. She has also been receiving flagyl and
vancomycin for c.diff and had multiple + C-diffs and has on and
off diarrhea. She was afebrible and was tolerating being
capped. Viral panel, legionella negative as were blood
cultures. Her aztrenoam was stopped and started on Meropenam and
continued on Colistin for pseudomonas, plan for 2 week course
per ID with an end date of [**2-16**]. She will need her creatnine
checked at least every other day while she is on colisitin.
.
#. Respiratory failure: Secondary to bleomycin toxicity and
reccurent pna. She failed to be extubated and has trach.
Currently has increase amounts of sputum and has hx of
pseudomonas pna. She arrived trached and on [**Date Range **]. She has a
history of becoming anxious when on the trach mask in which
Ativan was effective for relief. Chest x-ray showed some
bilaterally intertitial opacities which may be due to some
pulmonary edema. She also has a history of sarcoidosis and is on
chronic steroids for this. She is on HD for fluid removal given
hx of CHF and poor renal tolerance of diuresing. Currently doing
well on and tolerated trach collar. she was capped during the
day and was ventilated overnight.
.
# Chronic Systolic Congetive Heart Failure: Hx of cardiomyopathy
due to adriamycin. Pt had prior EF of 30% during prior
hospitalizations. As per OHS notes, her EF was decreased to 10%
on [**2163-10-19**] with severe L ventricular systolic dysfx, dilated
hypokinetic R ventricle. Repeat Echo in [**Month (only) **] and in [**Month (only) **] her EF
remained at 10%. Her Lisinopril 20mg and carvedilol 25mg.
.
# CKI: Pt had creatine peaked at 3.2 in [**Month (only) **] with aggressive
diuresing to help with weaning off [**Month (only) **]. She also developed
hyperK and as per note was started on HD to help with fluid
removal, she is currently receiving HD for volume status
management (last on [**1-30**] and [**2-2**]. Current creatine at 1.8. she
may require dialysis when returns to LTAC as is starting to show
signs of volume overload, but respiratory status doing well.
.
# Chronic Anemia: Pt with hx of anemia of chronic disease that
was fully worked up. Last iron 92, TIBC of 126. Her hct
decreased from 33.8 in [**Month (only) **] to 25.1 on [**1-30**] and she received 2
units of PRBCs. Current Hct now stable at low 30s.
.
# Upper Ext DVT: pt was on lovenox which appear to have stop.
Uncertain the dates on the lovenox. No UE edema noted. She was
restarted lovenox- will continue for long term course given
history of DVT and factor V leiden. Her creatinine has been
stable around 1.5 however if her creatinine worsens she should
be switched to lovenox one a day.
.
# Code: Full (discussed with patient).
Daughter, HCP, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 107085**]
Medical Facility: floor- [**Telephone/Fax (1) 88287**]
PA page- [**Telephone/Fax (1) 107086**]
Medications on [**Telephone/Fax (1) **]:
1. Acetaminophen 650 mg PO/NG Q6H:PRN Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Wheezing
3. Ascorbic Acid (Liquid) 500 mg PO/NG DAILY
4. Aztreonam [**2152**] mg IV Q6H
5. NPH 5 Units Daily
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
7. Lisinopril 20 mg PO/NG DAILY
8. Calcium Acetate 667 mg PO/NG TID W/MEALS
9. Lorazepam 1 mg PO/NG Q6H:PRN Anxiety
10. Carbamide Peroxide 6.5% 5-10 DROP AD [**Hospital1 **] Duration:
11. Metoclopramide 5 mg PO/NG QIDACHS
12. Carvedilol 25 mg PO/NG [**Hospital1 **]
13. MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q6H
14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
15. PredniSONE 5 mg PO/NG DAILY
16. Cholestyramine 4 gm PO BID
17. Simethicone 40-80 mg PO/NG QID:PRN Abdominal Discomfort
18. Colistin 75 mg IH [**Hospital1 **]
19. Vancomycin Oral Liquid 250 mg PO/NG Q6H
20. Estrogens Conjugated 1 gm VG DAILY
21. Venlafaxine 37.5 mg PO TID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Fever.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/Wheezing.
3. ascorbic acid 500 mg/5 mL Syrup Sig: One (1) PO DAILY
(Daily).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q
12H (Every 12 Hours).
9. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
10. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) UNITS Subcutaneous once a day.
11. insulin lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous three times a day.
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Abdominal
Discomfort.
16. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
17. colistimethate sodium 150 mg Recon Soln Sig: One (1) Recon
Soln Injection [**Hospital1 **] (2 times a day).
18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
19. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Anxiety.
20. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
22. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis
Serous Otitis
Pneumonia (pseudomonas)
C. diff
Secondary Diagnosis
Chronic Systolic Congestive Heart failure
Chronic Renal Failure
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the ICU because there was concern that you
had an infection deep in your left ear. You had the ears, nose
and throat specialist evaluate you and they did not think that
you had a significant infection.
You were also evaluated by the infectious disease doctors during
your [**Name5 (PTitle) **]. There were a few changes to your antibiotics.
The IV Vancomycin, Aztreonam and Fagyl were discontinued however
your meropenam and colisitin were continued. They recommended a
2 week course with an end date of [**2-16**].
Medications changed during your [**Date Range **]
STOP Aztreonam
STOP Flagyl
Start Meropenam End [**2-16**]
Change Colisitin 150mg [**Hospital1 **] subcutaneous End [**2-16**]
Start Ranitidine 150mg daily
Followup Instructions:
Please follow up with ENT as an outpatient with Dr. [**Last Name (STitle) 3878**] as
an outpatient [**Telephone/Fax (1) 2349**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4756
} | Medical Text: Admission Date: [**2116-8-11**] Discharge Date: [**2116-8-14**]
Date of Birth: [**2057-7-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59M known for EtOH abuse and HTN initially presented to [**Hospital1 18**] ED
morning of [**8-11**] from [**Hospital 1680**] rehab for EtOH withdrawal, was
discharged back to [**Hospital1 1680**] and then represented to ED in PM of
[**8-11**] for concern for delerium tremens.
Per [**Hospital **] rehab records, pt's last drink was reportedly on
Sunday, [**8-9**]. He was sectioned to [**Hospital1 1680**] on [**8-10**] for rehab.
Initial ED course: 98.6 HR: 67 BP: 104/70 Resp: 18 O(2)Sat: 96%
RA. He complained of confusion, tremulousness, unsteady gait and
visual hallucinations which he could bring on by closing his
eyes. Labs significant for cr of 1.8, K 2.9, AG 15, CBC with
crit 32.4, wbc 5.9, plt 111. He was given 60mEq of K+ and given
valium. As per ED attending discharge, "The patient is not
actively withdrawing
from alcohol the emergency department as he has a CIWA scale
less than 10." He was discharged back to [**Hospital1 1680**] detox.
This afternoon, while back at [**Hospital1 1680**], he became more ataxic,
confused and aggressive and combative towards staff and was
subsequently brought back to [**Hospital1 18**] ED for re-evaluation of etoh
w/drawal. While at [**Hospital1 1680**], he apparently had two witnessed falls
without head trauma or LOC. Per nurse manager at [**Hospital1 1680**], he also
urinated on the floor and had one episode of NBNB vomiting 24hrs
prior to presentation in ED.
Second ED course: T97.8 P98 BP110/75 RR18 O2:98% RA. As per EMS,
orthostatics were checked and negative. He was reportedly
combative and confused but PE was unremarkable for any focal
neurologic findings with the exception of ataxia. He had no
stigmata of chronic liver disease and per hx obtained through
staff at [**Name (NI) 1680**], pt did not have any complaints of abdominal
pain, diarrhea, cough, headache, fever, chills.
Pt was given 5mg haldol and 2mg IV ativan. Labs were significant
for improved chem 7 with K now 3.5, and cr now 1.0. AG had
resolved. Mg was 1.3 and Ca 8.3. CBC grossly unchanged from
earlier in the day. Head CT without any acute findings.
EKG x2 revealed leftward axis deviation but otherwise
unremarkable.
While in the [**Name (NI) **] pt did not have any significant acid-base or
electrolyte disturbances, no hemodynamic or respiratory
instability, hyperthermia, tremors or tachycardia. As per
nursing signout, his CIWA score was 5 at time of transfer.
Past Medical History:
HTN
EtOH abuse with h/o DTs
depression
IBS
Social History:
divorced
- Tobacco:no
- Alcohol:yes
- Illicits:?
Family History:
Noncontributory
Physical Exam:
VS: Afebrile, 82, 118/68, RR 121 94%RA
General: sleeping, combative when awoken
HEENT: Refused this part of the exam
Neck:
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alseep, slightly combative, moving all extremities
Pertinent Results:
Admission Labs:
[**2116-8-11**] 12:30PM BLOOD WBC-5.9 RBC-3.22* Hgb-11.3* Hct-32.4*
MCV-101* MCH-35.1* MCHC-34.9 RDW-20.7* Plt Ct-114*
[**2116-8-11**] 12:30PM BLOOD Neuts-65.3 Lymphs-23.5 Monos-9.1 Eos-1.8
Baso-0.3
[**2116-8-11**] 12:30PM BLOOD Glucose-85 UreaN-20 Creat-1.8* Na-142
K-2.9* Cl-100 HCO3-27 AnGap-18
[**2116-8-11**] 11:00PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.3*
[**2116-8-11**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2116-8-11**] 01:45PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Relevant labs:
[**2116-8-12**] 04:38AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2116-8-12**] 04:38AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2116-8-12**] 04:38AM URINE RBC-4* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
Discharge labs:
[**2116-8-13**] 07:15AM BLOOD WBC-4.6 RBC-3.48* Hgb-12.2* Hct-35.6*
MCV-103* MCH-35.1* MCHC-34.2 RDW-20.8* Plt Ct-153
[**2116-8-13**] 07:15AM BLOOD PT-10.1 PTT-30.9 INR(PT)-0.9
[**2116-8-13**] 07:15AM BLOOD Glucose-100 UreaN-20 Creat-1.0 Na-141
K-3.5 Cl-104 HCO3-25 AnGap-16
[**2116-8-13**] 07:15AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.6
[**2116-8-13**] 07:15AM BLOOD VitB12-484 Folate-8.6
Imaging:
[**2116-8-11**] CXR PA/lat: Bilateral low lung volumes are noted with
crowding of bronchovascular markings. Cardiac silhouette is
accentuated by low lung volumes. Thoracic aorta is quite
tortuous and may be enlarged in ascending or descending
portions. Clinical correlation is indicated to see if
imaging is indicated. No acute focal consolidation, pleural
effusion or
pneumothorax.
[**2116-8-11**] non-contrast CT head: There is no evidence for acute
intracranial hemorrhage, large mass, mass effect, edema, or
hydrocephalus. There is preservation of [**Doctor Last Name 352**]-white matter
differentiation. The basal cisterns appear patent. Prominent
ventricles and sulci suggest age-related involutional changes.
Note is made of a persistent cavum septum pellucidum. The
visualized portions of the paranasal sinuses and mastoid air
cells appear well aerated. No acute bony abnormality is
detected.
IMPRESSION: No CT evidence for acute intracranial process.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 M with PMH EtOH abuse, IBS and depression,
admitted from [**Hospital1 1680**] for management of EtOH withdrawal and
concern for [**Hospital 90022**] hospital course complicated by [**Last Name (un) **].
ACTIVE ISSUES:
# Alcohol withdrawal, concern for DTs, Adverse Drug Reaction
- Patient was agitated on arrival and ataxic and there was
concern that he was going into DTs, despite being on librium at
the detox facility. In the ED he received 5mg Haldol for acute
agitation. He was admitted to the MICU for management of
withdrawal and close monitoring. He was not tachycardic or
hypertensive. In the MICU, he was treated with diazepam per CIWA
scale (most recently [**Doctor Last Name **] ~5), as well as thiamine and folate
(recently transitioned to PO). Non-contrast head CT (for eval
given falls) showed no ICH. After transfer to the floor,
patient was calm and appropriate, with little memory of what had
brought him to the hospital; he felt that his what had been
described to him was not consistent with his character.
Psychiatry was consulted to evaluate whether bizarre behavior at
[**Hospital1 1680**] may have had an alternative explanation. Consult
theorized that patient's presentation was more consistent with
benzodiazepene intoxication than alcohol withdrawal.
# Acute Renal Failure due to Dehydration:
Initial Cr was 1.8, but improved to 1.0 on second chem panel
without any intervention.
CHRONIC:
# Depression:
Patient reported history of depression, which was impetus for
him to resume excess alcohol consumption. He denied depression
during this admission. He was provided with resources by SW.
Psychiatry evaluation was performed who felt he was completely
safe to discharge, and was not particularly depressed at this
time. No SI/HI.
# thrombocytopenia/Anemia:
likely EtOH induced marrow suppression given h/o etoh abuse,
elevated MCV. Stable throughout admission
# Benign Hypertension:
No acute exacerbation of chronic issue, pt. was continued on
home dose of amlodipine.
TRANSITIONAL ISSUES:
# Caution with benzodiazepenes during withdrawal.
# Recommended to have close follow up for depression.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
start [**8-12**]
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
start on [**8-12**]
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Thiamine 500 mg IV DAILY Duration: 3 Days
RX *thiamine HCl 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Amlodipine 5 mg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every eight hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
alcohol withdarawal
benzodiazepine intoxication
SECONDARY DIAGNOSES:
HTN
depression/anxiety
IBS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were transferred to [**Hospital1 69**]
from [**Hospital 1680**] Hospital for concern that you were behaving
abnormally. You were treated for alcohol withdrawal, which may
have contributed to your symptoms. You were given
benzodiazepines, intravenous fluid and vitamin supplementation.
During this hospitalization, you returned to behaving like your
normal self. You were seen by the psychiatry team who believe
that your abnormal behavior may also have been in part due to
side effects from the medication used to treat your alcohol
withdrawal.
You complained of anxiety while in the hospital. We have given
you a 3 day prescription for an anti-anxiety medication to treat
your symptoms until you can see your primary care physician who
will take over management of your anxiety.
MEDICATION CHANGES:
START-lorazepam (Ativan) 0.5 mg by mouth as needed for anxiety,
up to one every 8 hours.
Followup Instructions:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11182**] [**Name8 (MD) **], NP
Location: [**Hospital1 **] FAMILY PHYSICIANS
Address: [**Street Address(2) 89231**], [**Hospital1 **],[**Numeric Identifier 89232**]
Phone: [**Telephone/Fax (1) 39393**]
Appt: [**8-18**] at 11:20am
NOTE: This appointment is with a member of Dr [**Last Name (STitle) **]??????s team as
part of your transition from the hospital back to your primary
care provider.
ICD9 Codes: 5849, 311, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4757
} | Medical Text: Admission Date: [**2179-7-22**] Discharge Date: [**2179-8-11**]
Date of Birth: [**2104-3-14**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Neomycin
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
ankle, thigh, penile edema
Major Surgical or Invasive Procedure:
In CCU had SWAN catheter placement for hemodynamic monitoring
History of Present Illness:
75 year old male with a history of ischemic cardiomyopathy and
EF 10-15% with history of progressive ankle, thigh, penile edema
over past 2.5 weeks. Weight has increased from baseline of
151-154 lbs to 159 lbs. He has been admitted in the past for
treatment of his CHF, including monitoring with a swan ganz
catheter. He has been taking his medications. He denies
increased DOE, SOB at rest, orthopnea, nocturia, but does note
increased fatigue. He has DDD/ICD (BiV placement considered too
risky). Complicating factors include recent cessation of
amiodarone/statin due to concern for myopathy leading to
weakness, however treatment reinstated since holding did not
increase strength. Also has CRF with recent creatinine of 1.6
and chronic hypotension with SBP at 90 mmHg. Coronary artery
disease status post anteriolateral myocardial infarction in
[**2174**]. PCI with stent placement in LAD and D1 in [**2175**],
complicated by apical thrombus, emergent CABG. LV anterioapical
aneurysm. CHF with EF 14% from ETT-MIBI, Swan catheter in [**2175**]
had evidence of elevated left and right sided pressures. At
that time diuresed with IV lasix and milrinone with improvment
of pressures (to wedge less than 20, diuresed 18 liters). Echo
[**1-21**] LAE, LV dilatation, EF 10-15% severe global LVHK, severe
global RV free wall HK, 4+MR, 4+TR, mod Pulm HTN.
Past Medical History:
1. Coronary artery disease status post anteriolateral
myocardialinfarction in [**2174**]. PCI with stent placement in LAD
and D1 in [**2175**], complicated by apical thrombus, emergent CABG.
LV anterioapical aneurism.2. Congestive heart failure with
anejection fraction of 10 to 15%.3. Gastrointestinal bleed
secondary to small bowel AVMs.4. Atrial fibrillation status post
pacer DDD and AICD.5. Hypercholesterolemia.6. Hypertension.7.
Benign prostatic hypertrophy.8. Depression.9. Eczema.10. Anemia
with a baseline hematocrit of 27 to 32.11. Chronic renal failure
with a baseline creatinine of 2.0.12. MRSA colonization.13.
Status post stroke.14. Gastroesophageal reflux disease.15.
Status post appendectomy.
Social History:
The patient lives with his wife and his adopted son who is 8. He
has a fifty pack year history of smoking, but quit many years
ago. He drinks one to two glasses of alcohol per day.
Family History:
Non-contributory
Physical Exam:
Vitals T 95.5 P 75 BP 70/48 Resp 20 96%RA
Gen Alert, oriented, cooperative male in NAD
HEENT PERRLA, MMM, OP clear
Neck JVD at 15 cm, no lymphadenopathy or thyromegally
Thorax Scar on chest, crackles and wheezes at left base
CV RRR, S1,S2,S3, Systolic murmer at lt sternal base and apex
[**1-23**]
Abd Soft, slightly distended, no ascites, NT/ND +BS
Ext 3+ edema to just below the knee, no cyanosis
Neuro Intact
Pertinent Results:
[**2179-8-11**] 09:30AM BLOOD WBC-4.6 RBC-4.06* Hgb-11.2* Hct-35.3*
MCV-87 MCH-27.6 MCHC-31.7 RDW-17.2* Plt Ct-257
[**2179-8-11**] 09:30AM BLOOD Plt Ct-257
[**2179-8-11**] 09:30AM BLOOD Glucose-143* UreaN-25* Creat-1.3* Na-138
K-3.5 Cl-98 HCO3-27 AnGap-17
[**2179-8-11**] 09:30AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.1
[**2179-7-23**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
Brief Hospital Course:
1. CHF - This 75 year old male with a history of ischemic
cardiomyopathy EF 14% from ETT-MIBI presented with incresing
edema indicating acute CHF exacerbation. Upon admission
aggressive diuresis was started with the goal to get back to his
dry weight of 151-154lbs. Nesiritide drip was started and he
was stareted on Dopamine drip to maintain SBP >90. Upon further
evaluation it was determined that he would benefit from having
more tailored CHF therapy including monitoring with a SWAN
catheter. He was transferred to the CCU.
In the CCU a SWAN was placed and his initial readings were
PCWP 38, PA 56/24. He was continued on Dopamine and Nesiritide.
His ICD was interrogated and found to be working well, he was
being safety paced. After four days in the CCU he had diuresed
from 75 to 69.4 kg with Dopamine, Lasix, and Nesiritide.
Captopril and Altactone were started. The swan was dc'd and he
was transfered back to the floor for further management. His
swan ganz readings upon transfer to the floor were: CVP 12, PAP
51/18, CO 5.3.
Initially on the floor he was continued on Captopril,
Aldactone, Nesiritide, and bolus Lasix. He was converted from
Nesiritide and IV Lasix to Captopril and PO Lasix. After a few
days on the floor he had some increased edema and was more
aggressively diuresed with Dopamine and IV Lasix. His pressure
was very labile and it was difficult to stop the Dopamine, which
was maintaining his SBP >90. He was started on Sinemet for Dopa
stimulation and Aminophyline. As these medications were
titrated up we were able to wean off the IV Dopamine and he
maintained his blood pressure well. He was converted to oral
medications with his final regimen as below. He was on the
floor for a total of 14 days after transfer out of the CCU.
His discharge weight was 141 lbs. He had limited ankle edema
>1+ and no crackles on exam. He had no tremors from the
Aminophyline or Sinemet. Generally he is doing very well on
his current oral regimen.
2. CAD- He is s/p PCI with stent placement in LAD and D1 in
[**2175**], complicated by apical thrombus, emergent CABG. Since he
could not be on aspirin due to severe GI bleed he was not
treated with any. Initially his B-blocker and ACE-I were held
due to hypotension, but were restarted on the floor prior to
discharge. One set of enzymes was drawn which showed a troponin
of 0.6, this was felt to be demand ischemia due to fluid
overload.
3. Valves- He has severe 4+MR and 4+TR. An Echo here showed:
"The left atrium is markedly dilated. The right atrium is
markedly dilated. The left ventricular cavity is severely
dilated. There is akinesis of the septum. The is a posterior
apical aneurysm. There is hypokinesis of the remaining walls
with some preservation of the basal lateral and inferolateral
walls. Overall left ventricular systolic function is severely
depressed (ejection fraction 10%). A left apical thrombus
cannot be fully excluded. The right ventricular cavity is
dilated. The basal segment of the right ventricular contracts.
The aortic valve leaflets (3) are mildly thickened but
not stenotic. Severe (4+) mitral regurgitation is seen. Moderate
to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery
systolic hypertension. Mild to moderate pulmonic regurgitation
is seen.
Compared to the prior study of [**2179-2-10**] (tape not available for
review), there
has been a small increase in the pulmonary artery systolic
pressures. The
posterior apical aneurysm was not previously described." His
valve disease was unchanged from previous therefore ruling out
worsening valve disease as a cause of his acute exacerbation of
CHF.
4. CRI- His baseline creatinine is 1.6, we continued to monitor
his creatinine during his hospital stay and it was 1.2 at
discharge. His SBP was maintained greater than 90 throughout
his hospital stay to keep his kidneys adequately perfused.
5. GERD-He was continued on protonix for his GERD throughout his
hospital stay. He had no evidence of GI bleed.
6. Depression-He was continued on Zoloft throughout his hospital
stay. He was started on Olanzapine at night secondary to some
increased confusion and sundowning while in the CCU. It was
continued on the floor as it assisted with his sleeping and he
had no further episodes of confusion.
7. Atrial fibrillation: The patient has a pacemaker. He is
not on anticoagulation secondary to his chronic gastrointestinal
bleed.
8. Anemia: His HCT was stable throughout his hospital stay and
was 35.3 on discharge.
Medications on Admission:
1. Toprol XL 25 mg/day 2. Lasix 80mg BID3. Aldactone 12.5mg/day
4. Rabeprazole 20mg [**Hospital1 **] 5. Digoxin 0.125mg QD 6. Zoloft 200mg QD
7. MVI QD8. Procrit 30,000 units/week 9. Lisinopril 7.5mg/day
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QD (once a day) as
needed for heart failure.
14. Aminophylline 200 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
15. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
16. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
17. Carbidopa-Levodopa 10-100 mg Tablet Sig: Four (4) Tablet PO
QID (4 times a day).
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
CHF (EF 10-15%) had less than 6 month life expectancy
CAD
A.flutter
HTN
Depression
GERD
Discharge Condition:
stable, same level of ability as prior to admission
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by > 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 ml/day
Take all of your medications
Return to the hospital if you have any shortnes of breath, chest
pain, leg swelling
Followup Instructions:
Call to make appointment for Follow up with primary care doctor
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 29102**] in [**11-20**] weeks.
Call to make appointment for Follow up with Dr. [**First Name (STitle) 2031**] ([**Telephone/Fax (1) 24136**] in [**11-20**] weeks.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 4280, 4240, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4758
} | Medical Text: Admission Date: [**2176-6-15**] Discharge Date: [**2176-7-8**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
hemodialysis access inserted [**2176-6-28**]
Percutaneous tracheostomy [**2176-7-2**]
PEG placement [**2176-7-2**]
History of Present Illness:
89 yo M w/ h/o R medullary stroke '[**70**], dementia, CAD, htn,
hyperchol, and h/o AAA + femoral aneursyms s/p repair admitted
[**2176-6-15**] w/ c/o speech slurring/L facial droop, confusion, and R
hand/leg weakness. Intubated in the ER for hypoxic respiratory
failure.
Past Medical History:
dementia, right medullary stroke ([**2170**]), CAD s/p CABG [**86**] yrs
ago, CHF (EF 20%), htn, hyperchol, AAA s/p repair '[**59**], femoral
aneurysm repair, PVD, CRI (baseline 2-2.4)
Social History:
He is a retired attorney who lives at home w/ a 24 hour
assistant. Before admission, he was ambulatory, dressed
himself. Does not use tobacco, alcohol, or other illicit drugs.
Family History:
No h/o stroke in family.
No h/o aneurysm.
Physical Exam:
Gen: nonverbal, unresponsive, agitates to stimuli
heent: perrla (3->2mm), corneal reflexes intact, no doll's eyes,
trach in place w/ no erythema or drainage
cv: s1/s2; no s3/s4/m/r
pulm: coarse BS t/o B, no crackles or wheezes
abd: scaphoid, soft, NT, +BS, PEG tube in place w/ no erythema
or drainage
ext: 2+ pitting edema to knees B, 1+ pitting edema to elbow in
LUE, 2+ R pulses B, DP pulses non-palpable [**1-29**] edema
neuro: moves both LE and RUE spontaneously, withdraws to pain in
all extremities, bilateral upgoing toes and hyperreflex in bilat
UE
Pertinent Results:
[**2176-7-6**] 05:09AM BLOOD WBC-7.6 RBC-3.55* Hgb-9.5* Hct-31.5*
MCV-89 MCH-26.8* MCHC-30.1* RDW-16.7* Plt Ct-127*
[**2176-6-30**] 02:28AM BLOOD Neuts-89.5* Lymphs-4.8* Monos-2.7 Eos-2.8
Baso-0.3
[**2176-6-15**] 10:20PM BLOOD FDP-10-40
[**2176-6-15**] 01:51PM BLOOD Fibrino-128* D-Dimer-5422*
[**2176-7-6**] 05:09AM BLOOD Glucose-97 UreaN-50* Creat-2.9* Na-146*
K-4.1 Cl-110* HCO3-25 AnGap-15
[**2176-7-5**] 04:41AM BLOOD ALT-33 AST-100* LD(LDH)-202 AlkPhos-58
TotBili-0.5
[**2176-7-6**] 05:09AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
[**2176-6-15**] 01:51PM BLOOD calTIBC-311 Ferritn-70 TRF-239
[**2176-7-3**] 12:20 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2176-7-5**]**
GRAM STAIN (Final [**2176-7-3**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2176-7-5**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2176-6-26**] 4:00 pm BLOOD CULTURE CORDIS.
**FINAL REPORT [**2176-7-2**]**
AEROBIC BOTTLE (Final [**2176-7-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2176-7-2**]): NO GROWTH.
[**2176-6-26**] 3:05 pm BLOOD CULTURE CVP.
**FINAL REPORT [**2176-7-2**]**
AEROBIC BOTTLE (Final [**2176-7-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2176-7-2**]): NO GROWTH
[**2176-6-25**] 9:41 pm URINE
**FINAL REPORT [**2176-6-27**]**
URINE CULTURE (Final [**2176-6-27**]): NO GROWTH.
Brief Hospital Course:
NSURG course: Noncontrast head CT revealed bilateral frontal
contusions w/ SAH c/w trauma, though patient never told his
family about a past fall but is now nonverbal. Serial CTs show
stable contusion and stable SAH. Course also significant for new
ARF on CRI w/diuresis, resp failure, chf. Transferred to MICU
for further management of ongoing acute on chronic renal failure
and ventilator dependent.
MICU Course: Pt transferred to MICU w/ stable frontal cerebral
contusions and SAH, hypoxic respiratory failure, acute on
chronic renal failure, CHF, and iron deficiency anemia.
1. Cerebral contusions/SAH: on transfer, he had a stable
neuro exam: nonverbal, unresponsive; moving both LE and the RUE
spontaneously; withdrawing all limbs from pain. He was treated
with lopressor, hydralazine, and a nitrate to maintain SBP in
the 140s; his outpatient ASA and Plavix were held to avoid
exacerbating cerebral hemorrhage. His neurological status
remained stable throughout his MICU stay.
2. Hypoxic respiratory failure: the patient was intubated on
SIMV on transfer. His respiratory failure was thought to be [**1-29**]
a combination of pulmonary edema and community acquired PNA. He
had just finished a 10-day course of levaquin for PNA upon
transfer. He was observed to have a variable respiratory drive,
often with poor minute ventilation, likely [**1-29**] neuro insult. He
was transitioned from SIMV to MMV with maintenance of good O2
sats. He underwent tracheostomy on [**7-2**] in preparation for
long-term ventilator dependence. He received hemodialysis
multiple times in the MICU for fluid removal in order to proceed
towards extubation. At DC, he remains stable on MMV with a
tenuous respiratory drive.
3. Acute on chronic renal failure: on transfer, the pt
demonstrated ARF likely [**1-29**] overdiuresis in the setting of
intravascular volume depletion, with a creatinine of 4.1
(baseline 2-2.2). He was treated with IV hydration to maintain
even fluid status, and underwent HD for total body fluid
removal. His renal fxn improved over his MICU course, with
creatinine down to 2.9 at DC.
4. CHF: on transfer, he had improving pulmonary edema [**1-29**]
CHF and hypoalbuminemia. He was treated with lopressor,
hydralazine, and isosorbide dinitrate, with rapid resolution of
pulm edema. On DC, he has no pulm edema by clinical exam. Can
consider changing hydralazine/isosorbide over to ace-inhibitor
as tolerates as pt likely to remain on hemodialysis.
5. Anemia: labs indicate an iron deficiency anemia, likely
[**1-29**] chronic slow GI bleed as stool is hemoccult positive. On
[**6-30**] HCT dropped below 28; he received 1U PRBCs, with appropriate
increase in HCT to above 30. HCT remained stable after
transfusion until DC. Will start niferex given iron studies of
iron 36, ferritin 70, tibc 311.
6. GI/FEN: Pt is s/p feeding tube placement. He will continue
with his tube feeds. Pt had episode of increased sodium which
had improved with free water boluses through his NG tube.
Discharge Medications:
Active Medications [**Known lastname 109320**],[**Known firstname **]
1. Acetaminophen 650 mg PO Q4-6H:PRN Order date: [**6-27**] @ 1809
2. Atorvastatin 10 mg PO QD Order date: [**6-27**] @ 1809
3. Bisacodyl 10 mg PO/PR [**Hospital1 **]:PRN Order date: [**6-27**] @ 1809
4. Calcium Gluconate 2 gm / 100 ml IV PRN for Ca<8.5 Order
date: [**6-27**] @ 1809
5. Docusate Sodium (Liquid) 100 mg PO BID Order date: [**6-27**] @
1809
6. Hydralazine HCl 20 mg NG Q6H hold for MAP < 60 Order date:
[**7-3**] @ 1043
7. Isosorbide Dinitrate 20 mg NG TID hold for MAP < 60 Order
date: [**7-3**] @ 1438
8. Lansoprazole Oral Suspension 30 mg NG QD Order date: [**6-27**] @
1809
9. Lorazepam 0.5 mg IV Q4-6H:PRN agitation Order date: [**7-1**] @
[**2123**]
10. Metoprolol 50 mg PO TID hold for sbp < 120 or hr < 60 Order
date: [**7-4**] @ 1357
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Primary Diagnosis: subarachnoid hemorrhage with bilateral
frontal cerebral contusions.
2. Secondary Diagnoses: coronary artery disease, congestive
heart failure, iron deficiency anemia.
Discharge Condition:
Stable.
Discharge Instructions:
Wean ventilator as tolerated.
Continue tube feeds through PEG tube.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 4280, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4759
} | Medical Text: Admission Date: [**2159-5-16**] Discharge Date: [**2159-6-1**]
Date of Birth: [**2108-12-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Known aneurysm, now enlarged in size
Major Surgical or Invasive Procedure:
1.Right sided pterional craniotomy for right-sided ICA
bifurcation aneurysm clipping.
2. Microsurgical dissection.
3. Duroplasty.
History of Present Illness:
The patient is a 50-year-old female that was found to have an
incidentally discovered right-sided ICA bifurcation aneurysm.
This aneurysm has been known for several years. It is followed
up by sequential scans. The patient has now undergone a formal
angiogram by Dr.[**Name (NI) 10136**] service on [**2159-4-5**]. The
catheter angiogram with gadolinium has confirmed a 9 x 5.5mm
bilobed aneurysm at the bifurcation of the right anterior and
middle cerebral arteries. It appears to have a wide neck
measuring approximately 4.5 to 5mm. Overall, the patient has
done well and remains clinically intact and stable. She has
done [**Location (un) 1131**] on the issue and decided that she does not want to
undergo coiling which is technically difficult with wide neck
aneurysms anyway. The patient opted to have an open surgery and
wants to have definite occlusion by clipping. She is seen for
surgical counseling in neurosurgery office.
Currently, she denies any new symptoms such as headaches,
nausea, vomiting, or dizziness. The patient has no seizures or
focal neurological deficits. She had persistent balance problems
secondary to spinal and cervical stenosis.
Past Medical History:
- DM type I x 29 years - last A1c 11.3 [**5-10**], followed at the
[**Last Name (un) **]. CHecks FS QID, vary widely from 40's to 400's.
- cardiomyopathy, EF 15-20% from TTE yesterday, on Coumadin
- CKD s/p transplant in [**2152**], Cr 1.9 to 2.9 range since [**1-9**]
- Intracranial right ICA aneurysm, diagnosed "several years
ago,"
gets yearly imaging. 5mm [**2154**], 8mm on [**2159-2-7**] MRA.
- History of C4-5 and C5-6 anterior decompression and fusion
after MVA [**2157**], Dr. [**Last Name (STitle) 363**]
- ulnar nerve impingement bilaterally
- Hypertension
- Hepatitis C acquired via transfusion for menses that were
hemorrhagic, now menopausal.
- Rotator cuff repair
- CMV [**2155**]
- E.coli UTI in [**12-11**]
- right carpal tunnel surgically released
Social History:
Pt Lives at home with son and his wife and their 4 children. Pt
works at [**Location (un) 686**] District Court
EtOH - used to drink, none in 9 years
Tob - 1ppd for 27 years, quit about 8 years ago
Family History:
Sister died of [**Name (NI) 101497**], many other family members with type 1 and 2
DM
Physical Exam:
VITALS: 97.8, 144/88, 98, 18, 98% RA, FS 99-210
GEN: no acute distress, pleasant woman that appears younger than
stated age
NECK: limited ROM
NEURO:
Mental status:
Patient is alert, awake, pleasant affect. Oriented to person,
place, time. Good attention - tells a coherant story.
Language is fluent with good comprehension, repitition, naming,
no dysarthria. No apraxia, agnosias, no neglect. Able to
calculate, no left/right mismatch. Registration [**4-10**] objects.
Recalls [**4-10**] objects after 3 minutes.
Cranial Nerves:
I: deferred
II: Visual fields: full to left/right/upper/lower fields.
Fundoscopic exam: discs flat, fundi clear, no hemorrhages or
exudates. Pupils: 3->2 mm, consensual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis.
- UPON DISCHARGE PERSISTANT R SIDED UPPER LID PTOSIS. NO OTHER
FACIAL ASSYMETRY
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: symmetric face
VIII: hearing intact to finger rubs
IX, X: Symmetric elevation of palate.
[**Doctor First Name 81**]: SCM and trapezius [**5-11**] bilaterally
XII: tongue midline without atrophy or fasciculations.
Sensory:
Normal touch, proprioception, pinprick. Decreased cold in a
stocking/glove distribution. No extinction to double
simultaneous stimulation.
Motor:
Wasting bilateral APB, FDI, EDB bulk, mildly increased tone
legs.
No fasciculations or drift. + postural tremor low amplitude
worse with motion. No asterixis.
D T B WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**]
RT: 5 4 5 5 5 5 5 4 5 4- 5 5 4+
LEFT: 5 4 4+ 5 5 5 5 4 5 4- 5 5 4+
Reflexes: + [**Doctor Last Name **] bilaterally. No Jaw jerk. Crossed
adductors. SLIGHTLY MORE HYPERREFLEXIC ON L PATELLAR.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 3 3 tr 3 tr up
LEFT: 3 3 2 3 tr up
Coordination:
Normal finger-to-nose (tremor constant throughout testing, worse
with posture and action), heel-to-shin, RAMs.
Gait:
Gait is antalgic, favors the left leg.
Pertinent Results:
CXR [**5-17**]:
IMPRESSION: NG tube in left lower lobe segmental bronchus. This
has been communicated immediately to Dr. [**Last Name (STitle) **] at the time of
the review of the study at approximately 10 p.m. on [**2159-5-16**].
.
Angeography:
IMPRESSION: No evidence of perfusion to the clipped right ICA
bifurcation aneurysm. No evidence of residual aneurysm. The
right ICA, MCA, ACA and the major branches are patent.
.
CT [**5-18**]:
IMPRESSION: Again noted is intraparenchymal hemorrhage within
the right temporal lobe with surrounding edema that measures
slightly larger compared to prior study. Increase in
high-density material seen within the right frontal extra-axial
space with slight increase in leftward shift of midline
structures. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13013**] at 6:45 a.m. on [**5-18**], [**2159**].
.
NOTE ADDED AT ATTENDING REVIEW: The increase in extra axial
fluid is expected as fluid replaces air at the surgical site.
The slight change in the appearance of the post operative
hemorrhage in the temporal lobe does not necessarily reflect
increased bleeding.
.
[**5-19**] CT:
IMPRESSION: Stable appearance of right inferior frontotemporal
intraparenchymal hemorrhage with surrounding edema.
Post-surgical changes from right frontal craniotomy. No new
hemorrhage, hydrocephalus or increased shift of normally midline
structures is identified.
.
[**5-22**] CT:
FINDINGS: Examination is essentially unchanged from the previous
study. Again is noted increased density in middle cranial fossa
consistent with hemorrhage within the temporal lobe and/or
subjacent to it. There is some gas still seen in the right
frontal extra-axial compartment. Artifact to the aneurysm
clipping is again noted. There is low density in the head of the
caudate consistent with infarction. There are some malacic
changes in the right frontal lobe.
.
IMPRESSION: Stable appearance when compared to previous
examination.
.
[**5-24**] CXR:
The previously identified opacities in both lower lobes have
been markedly improving. The lungs are clear otherwise. The
heart and mediastinum are within normal limits. The right
jugular IV catheter remains in place. No pneumothorax is
identified.
.
[**5-24**] Renal US:
FINDINGS:
The right lower quadrant renal transplant measures 13.8 cm in
length, which is unchanged from the prior study. Cortical
echogenicity is likely within normal limits but may be mildly
increased. Cortical-medullary differentiation persists. There
are no renal masses, hydronephrosis, or calculi. Arterial flow
is identified within the upper, mid and lower pole wrist with
resistive indices up to 0.90 which are increased from the prior
study. Renal vein is patent. No perinephric fluid collections.
IMPRESSION:
Right lower quadrant renal transplant without hydronephrosis.
All vessels patent though resistive indices are slightly
increased from the prior study, which is nonspecific.
.
[**5-25**] EKG:
Sinus rhythm. Left atrial abnormality. First degree A-V block.
Left
bundle-branch block. Compared to the previous tracing of [**2159-5-19**]
no significant diagnostic change.
.
[**5-28**] US:
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left internal
jugular, subclavian, axillary, brachial, and basilic veins were
performed. There is a small amount of non-occlusive thrombus
within the left internal jugular vein. The left subclavian,
axillary, and brachial veins are patent with normal flow,
augmentation, compressibility, and waveforms. The basilic vein
is patent.
.
IMPRESSION: Small amount of non-occlusive thrombus within the
left internal jugular vein. No evidence of left upper extremity
DVT.
Cx negative - BCx, UCx negative
.
[**5-31**] US:
LEFT UPPER EXTREMITY DVT STUDY: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**]
of the left IJ, left subclavian, left axillary, and left
brachial veins were performed. There is again noted a small
nonocclusive thrombus in the left internal jugular vein in the
neck, which is probably slightly decreased when compared to the
prior study. No new thrombus is identified. The other visualized
veins are unremarkable.
IMPRESSION: Persistent tiny nonocclusive thrombus in the left
internal jugular vein in the neck. It appears to be slightly
decreased when compared to the prior study.
.
CT [**5-29**]:
COMPARISON: Compared to the CT of [**2159-5-22**], there is
decreased density within the right temporal lobe hematoma,
indicating maturing hemorrhage. Low densities within the head of
the caudate and temporal lobes secondary to infarction are
stable. Mild edema and mass effect slightly reduced. The
ventricles are not dilated. The small extra-axial fluid
collection at the craniotomy site is stable with no evidence for
new intracranial hemorrhage. Post- surgical soft tissue swelling
is unchanged. Aneurysm clip related artifact again present.
IMPRESSION: Slight improvement from [**2159-5-22**] with no
evidence for new hemorrhage.
.
VRE/MRSA SCREENS NEGATIVE
.
Labs upon d/c:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-6-1**] 04:50AM 6.9 3.26* 8.8* 26.9* 82 26.9* 32.6 18.9*
611*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2159-5-28**] 05:57AM 68.7 22.7 5.5 2.8 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Microcy
[**2159-5-28**] 05:57AM 1+ 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2159-6-1**] 04:50AM 611*
HEMOLYTIC WORKUP Ret Aut
[**2159-5-28**] 05:57AM 1.7
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-6-1**] 04:50AM 137* 14 1.9* 146* 3.8 111* 26 13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2159-5-29**] 06:09AM 354* 0.1
OTHER ENZYMES & BILIRUBINS Lipase
[**2159-5-25**] 06:25AM 20
CPK ISOENZYMES CK-MB cTropnT
[**2159-5-19**] 12:10AM 4 0.01
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2159-6-1**] 04:50AM 8.8 3.1 1.6
HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2159-5-29**] 06:09AM 87
LIPID/CHOLESTEROL Cholest Triglyc
[**2159-5-20**] 03:22AM 89
OTHER CHEMISTRY Osmolal
[**2159-5-22**] 03:17AM 314*
THYROID PTH
[**2159-5-23**] 01:43PM 54
NEUROPSYCHIATRIC Phenyto
[**2159-5-20**] 07:30AM 15.5
[**2159-5-20**] 03:22AM 17.1
TOXICOLOGY, SERUM AND OTHER DRUGS FK506 rapmycn
[**2159-6-1**] 04:50AM 4.9*
[**2159-6-1**] 04:50AM 5.8
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is 50 y.o. F with DM 1, s/p cadaveric renal
transplant '[**52**], admitted for clipping of right sided bilobed
middle cerebral artery bifurcation aneurysm on [**2159-5-16**],
complicated by left temporal contusion. Patient was observed
Neuro ICU for hemodynamic and close neurologic monitoring.
Failed 3 attempt of placement of NGT/OG for immunosuppressive
drug as well as for nutrition immediate postoperative period
with LLL PNA as complication. Post operative head CT revealed
right temporal contusion which has bees stable in appearance in
serial cat scans of the head. The course was complicated by
persistent somnolence attributed to Keppra and anemia and
improving ARF with resolving CHF.
..............................................................
.
Neuro: Her initial postoperative neurologic exam off sedation
showed normal extremity response to pain but right eye ptosis,
IIIrd nerve palsy. Pupils are sluggishly reactive 3-2mm
bilaterally. She had a cerebral arteriogram on [**2159-5-17**]. There
were no immediate complications during arteriogram. Arteriogram
revealed a surgical clip is seen in the region of the previously
seen ICA bifurcation aneurysm on the right. There is no
evidence of residual perfusion of this aneurysm. The superior
sagittal sinus, right transverse sinus, right sigmoid sinus and
upstream portion of the right internal jugular vein are widely
patent as well as the right ICA, MCA, ACA and the major branches
are patent. Patient remained with R eye ptosis, and improvement
in III nerve palsy that was presumed to be due to operation and
neurosurgery did not feel certain whether it was going to be
reversed. Patient with increased somnolence during the day and
several episodes of [**Last Name (un) 6055**]-stoke breathing suggesting central
apnea. She was evaluated by pulmonary service who also noted an
element for apnea and she was referred for outpatient sleep
study. R temporal contusion remained stable on CT, last one
[**5-29**] showed maturing hematoma without any evidence of new
hemorrhage. Patient with persistent somnolence although quickly
arrousable. The etiology of somnolence remained unclear and may
have been due to sleep apnea as described above. Patient was
also taken off Keppra after discussion with Dr. [**Last Name (STitle) **] and
somnolence improved slightly. She is to f/u with Dr. [**Last Name (STitle) **] in
6 months, CTA in 1 yr. There was no evidence of seizures while
in house.
.
# LLL PNA - Patient was found to have a LLL PNA on [**5-17**] CXR that
was obtained after
patient had a desaturation episode where her oxygen saturation
dropped to 86%. This may have been a complication of multiple
failed NGT placement attempts. Patient was initially placed on
Levo/Flagyl. Flagyl was subsequently discontinued. Her
saturation remained excellent on room air. Cultures were not
done as patient denied any sputum or fever. Repeat chest
radiograph on [**5-24**] showed marked improvement pneumonia and
pleural effusion. She completed 7 day course of Levaquin -last
dose 5/22.
.
Patient with DM nephropathy s/p renal transplant. Patient was
being followed by nephrology transplant service while in house.
Her creatinine at baseline is 2.0-3.0 with large fluctuations.
Patient's her creatinine was 2.9 on [**5-16**] preop, post arteriogram
peaked to 4.1, and was attributed likely due to peri-operative
hypotension and worsening renal failure. There was no evidence
of hydronephrosis on Renal ultrasound preformed on [**5-24**]. The
contrast during angiogram was unlikely to be a contributor since
Cr started rising 3 days after exposure. US evaluation of the
right lower quadrant renal transplant showed all vessels patent
though resistive indices are slightly increased from the prior
study, which is nonspecific. Microscopic urine sediment
confirmed ATN with FeNa 2.4 % on [**5-24**] with pr/cr of 1.7 .
Patient's Cr slowly improved to low 2.0s and she was restarted
on her regular CHF regiment included Losartan. Patient
tolerating small doses of Lasix prn as her renal function also
improved with diuresis. Patient was also continued on
sacrolimus/tacrolimus and the dosages were adjusted based on
daily values. Patient will f/u with Dr. [**First Name (STitle) 805**] as outpatient.
.
# Anemia - Patient with microcytic anemia. Work up revealed
guiac negative stool on [**5-29**]. FeStudies c/w nl Fe, low TIBC,
suggesting anemia of chronic diseases. nl B12/Folate [**2-12**].
Patient also noted to have low reticulocyte index, no
schistocytes on smear, LDH/hapto nl. She was continued on
Epogen and it was increased to compensate her anemia. Patient
was given 1 unit PRBC on [**5-26**] and her Hct remained stable for
the rest of her hospitalization. There was no evidence of
increasing hematoma on head CT and no other source of bleeding
was suspected.
.
# HTN - patient was managed on Metoprolol XL, Hydralazine and
Imdur were titrated off while she was restarted on Losartan and
subsequently Nifedipine CR was added to her regiment. Goal BP
was 140-150 to assure adequate renal perfusion.
.
# Pyuria - on [**2159-5-31**], although UCx was negative she was
empirically treated with cipro 250 [**Hospital1 **] x 7 days. Patient denied
any fever or urinary symptoms. She urinated well after removal
of the foley.
.
# LUE DVT - Patient was noted to have L arm swelling on [**5-28**].
Subsequent US showed non-occlusive thrombus in Left internal
jugular vein probably due to prior line placement. Patient's
was a high risk for anticoagulation due to guiac negative stools
but steadily decline hematocrit as described above. The risk
and benefits were discussed with the patient multiple times and
she agreed that the anticoagulation would be too risky not
knowing the source of her blood loss. Repeat US o [**5-31**] showed
tiny improved nonocclusive L IJ clot and it was decided to forgo
anticoagulation upon discharge with a knowledge of organizing
hematoma seen upon repeat CT.
.
# CHF - Patient with known nonischemic cardiomyopathy, and
initial volume overloaded likely due to worsening renal
function. Patient's trace edema improved with mild diuresis due
to prn lasix and while she was started on hydralazine and Imdur.
Patient's respiratory status was never compromised and slowly
her renal function improved. Patient subsequently was switched
from Hydral/Imdur to Losartan for afterload reduction. No Lasix
were Rx for home therapy. Patient will follow up with
Cardiologist @ [**Hospital1 2177**] or [**Hospital 1902**] clinic here. She may require
subsequent ICD eval and risk stratification.
.
# IDDM - patient Type I DM and was followed by [**Last Name (un) **] service
during her stay. She was maintained on insulin gtt while in the
ICU and subsequently switched to sliding scale with Lantus. Her
tight scale was maintained < 150 with at least 13 u Lantus even
when NPO.
.
# Full code
.
Follow up - patient will follow up with her renal doctor, her
PCP, [**Name10 (NameIs) **] and pulmonary clinic and also Dr.[**Last Name (STitle) **] in 6 months.
Medications on Admission:
tacrolimus 3", sirolimus 5', toprol XL 100', lipitor 20',
losartan 25', Zantac 75', Lantus/Novalog, tramadol 50',
?coumadin
Discharge Medications:
1. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for headache.
4. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*3*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
6. Tramadol 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day for 1 weeks.
Disp:*7 Tablet Sustained Release 24HR(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*1 cartridge* Refills:*3*
9. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*3*
10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
11. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO at bedtime.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*3*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
14. Epogen 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR.
Disp:*30 injection* Refills:*3*
15. Outpatient Physical Therapy
Please continue physical therapy 3x/week at home for as long as
needed
16. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*90 Capsule(s)* Refills:*3*
17. Sirolimus 1 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
Disp:*210 Tablet(s)* Refills:*3*
18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO qAM.
Disp:*120 Capsule(s)* Refills:*3*
19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units
Subcutaneous qACHS: as per your sliding scale.
Disp:*2 bottle* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
R MCA aneurysm
R temporal lobe contusion
Acute Renal Failure
Chronic Renal Insufficiency - s/p renal transplant
Obstructive Sleep Apnea
Anemia
Acidosis
Congestive Heart Failure
Pneumonia
IDDM
Hypertension
Hepatitis C
Discharge Condition:
Stable. Pt afebrile. Ambulating with cane. Oxygenating well.
Tolerating PO.
Discharge Instructions:
Please take all your medicatios as instructed.
.
It is important to keep all your appointment and follow up with
them as scheduled.
.
Please seek immediate medical attention if you experiences a
worsening headache, nausea/vomiting, increasing
numbness/weakness in any of your extremities, or if you noticed
slurred speech or worsening swallowing.
Followup Instructions:
Follow up with PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - [**6-12**], @ 11:30 am.
[**Telephone/Fax (1) 1260**]
.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], renal clinic, on [**2159-6-7**] @ 12
pm.
.
Follow up in sleep clinic once your symtpoms improved and call
[**Telephone/Fax (1) 16716**] to make an appointment. You will also need to make
a subsequent appointment with a pulmonary doctor - call ([**Telephone/Fax (1) 35871**] to make an appointment.
.
Follow up with Dr. [**Last Name (STitle) **] in 6 months. Call ([**Telephone/Fax (1) 88**] to
make an appointment.
.
Follow up with [**Hospital **] clinic ([**Telephone/Fax (1) 17240**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] -
[**6-8**] @ 11 am
.
Follow up with Dr. [**Last Name (STitle) 363**] re: your spine procedure. Call him to
make an appointment @ ([**Telephone/Fax (1) 11061**]
Completed by:[**2159-6-18**]
ICD9 Codes: 486, 4280, 5849, 2762, 5119, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4760
} | Medical Text: Admission Date: [**2177-11-25**] Discharge Date: [**2177-12-5**]
Date of Birth: [**2114-2-8**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
male with a past medical history of chronic obstructive
pulmonary disease, lung cancer, status post right
pneumonectomy in [**2175-1-26**], complicated by pulmonary artery
laceration, status post transtracheal catheter placement for
oxygen and suctioning who was in his usual state of health
until [**2177-11-24**] when he developed nausea, lower
abdominal pain, and projectile vomiting of nonbloody emesis.
He presented to the [**Hospital6 256**]
Emergency Room on [**2177-11-25**]. At that time he denied
diarrhea, constipation, fevers, chills, hematochezia and
bright red blood per rectum. He had dark stools at baseline
secondary to iron use. The stool was found to be guaiac
positive in the Emergency Department. In the Emergency
Department also his hematocrit value was 19, down from a
baseline of 31 one month previously and he was coagulopathic
with an INR of 9.8. Attempts to place a nasogastric tube in
the Emergency Department were unsuccessful. While in the
Emergency Department, he was transfused 4 units of packed red
blood cells, 2 units of fresh frozen plasma, and got 2 mg of
subcutaneous Vitamin K. The patient was admitted to the
Medicine Floor. Repeat hematocrit several hours later
dropped to a value of 13. The nasogastric tube was placed on
the floor with nasogastric lavage negative for fresh blood.
He was, at that point, transferred to the Medical Intensive
Care Unit. Workup while in the Medical Intensive Care Unit
included two esophagogastroduodenoscopies, both without fresh
blood or old blood but demonstrating a single raised 5 to 7
cm esophageal nodule on an erythematous base at approximately
25 cm. There was no evidence of stigmata of recent bleeding.
He was stabilized with a total of seven units of packed red
blood cells, seven units of fresh frozen plasma and one unit
of platelets. He also received intravenous fluid
resuscitation with normal saline. Computerized tomography
scan of the abdomen was performed which was negative for
diverticuli, perforation or retroperitoneal bleed.
Colonoscopy performed later in the hospital course showed
some polyps, diverticulosis of the sigmoid colon and
descending colon. Internal hemorrhoids were noted but no
stigmata of recent bleeding. The patient's coagulopathy was
improving. His hematocrit was stable, and he was transferred
to the General Medicine Floor on [**2177-11-28**]. Of note,
prior to transfer he developed swelling of the right upper
extremity and complained of pain of the right upper
extremity. Doppler ultrasound was performed which showed
evidence of a right axillary deep vein thrombosis.
PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease; 2. Lung cancer, status post right pneumonectomy in
[**2175-1-26**] complicated by pulmonary artery laceration; 3.
Prostate cancer, status post prostatectomy; 4. History of
perioperative pulmonary embolism; 5. Atrial fibrillation on
Coumadin; 6. Hypertension; 7. Diabetes mellitus 2,
insulin-requiring neuropathy; 8. Gastroesophageal reflux
disease; 9. Status post transtracheal catheter placement for
oxygen and suctioning; 10. Cataracts; 11. Anxiety; 12.
History of transient ischemic attacks; 13. Obstructive sleep
apnea; 14. Hypercholesterolemia; 15. Vitamin B12
deficiency.
ALLERGIES: Levaquin causes QT interval prolongations.
MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o.
q.d.; 2. Lasix 80 mg p.o. b.i.d.; 3. Neurontin 100 mg p.o.
q.d.; 4. Paroxetine 30 mg p.o. q.d.; 5. Iron sulfate 325 mg
p.o. b.i.d.; 6. Colace 100 mg p.o. b.i.d.; 7. Glyburide 5
mg p.o. q.d.; 8. Vitamin B12 1000 mcg p.o. b.i.d.; 9.
Amiodarone 200 mg p.o. q.d.; 10. Lipitor 10 mg p.o. q.d.;
11. Coumadin 5 mg p.o. q.d.; 12. Aspirin 325 mg p.o. q.d.;
13. Scopolamine patch transdermal, apply every three days;
14. Advair discus one puff b.i.d.; 15. Potassium chloride
40 mEq p.o. b.i.d.; 16. Senna 2 tablets p.o. b.i.d. as
needed for constipation; 17. Percocet 1 to 2 tablets as
needed for pain; 18. Ipratropium nebulizer t.i.d.; 19.
Bactrim double strength p.o. b.i.d.; 20. Augmentin; 21.
Multivitamin p.o. q.d.; 22. Regular insulin sliding scale.
FAMILY HISTORY: The patient reports that his mother has
coronary artery disease.
SOCIAL HISTORY: The patient lives with his wife, retired,
worked previously in construction. He reports a 160 pack
year tobacco history, quit in [**2174**], quit alcohol in [**2173**]. No
history of intravenous drug use.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs with temperature of 96.8, blood pressure
90/55, heart rate 90, respiratory rate 12, oxygen saturation
96% on 3 liters. General appearance: Well developed, obese
white male, pleasant, comfortable in no acute distress.
Head, eyes, ears, nose and throat: Normocephalic,
atraumatic, pupils equal, round and reactive to light and
accommodation. Sclera and conjunctiva anicteric.
Conjunctiva not injected. Oropharynx clear. [**Year (4 digits) **] mucosa
dry. Neck: Supple, no masses or lymphadenopathy.
Tracheostomy site, clean, dry and intact. Lungs: Right lung
with no breath sounds, left lung with fair air movement,
transmitted upper airway sounds, scattered rhonchi.
Cardiovascular: Regular rate and rhythm, S1 and S2 heart
sounds auscultated, no murmurs, rubs or gallops. Abdomen:
Soft, mildly tender to palpation, nondistended, positive
normoactive bowel sounds. No rebound or guarding.
Extremities: No cyanosis, clubbing or edema. Neurological
examination: Nonfocal.
LABORATORY DATA: Laboratory data upon admission revealed
complete blood count demonstrated a white blood cell count
19.2, hematocrit 19.0, platelets 381. Coagulation profile
showed PT 38.5, PTT 38.0, INR 9.8. Serum chemistries showed
sodium 139, potassium 3.7, chloride 96, bicarbonate 30, BUN
52, creatinine 1.3, glucose 196. Liver function tests showed
ALT 18, AST 26, amylase 23, lipase 24, albumin 3.4, alkaline
phosphatase 100. Cardiac enzymes showed creatinine kinase
82, troponin I 0.04. Chest x-ray was negative for any acute
pulmonary process. Abdominal x-ray demonstrated
opacification of the right lung base. The left lung base was
clear. There was no free air in the abdomen. There was a
large amount of fecal material in the right colon. There was
a normal bowel gas pattern. There was no evidence of
obstruction. Later computerized tomography scan of the
abdomen and pelvis demonstrated no intra-abdominal abscess,
bowel inflammation, evidence of perforated ulcer,
appendicitis or diverticulitis. Electrocardiogram showed
normal sinus rhythm at 93 beats/minute, normal axis,
prolonged QT interval, no left ventricular hypertrophy, T
wave inversions were noted in leads V1 and V2 which were new.
No acute ST elevations or depressions noted. This was
compared with the prior electrocardiogram from [**2177-10-9**].
HOSPITAL COURSE: In summary, this is a 63 year old male with
past medical history of chronic obstructive pulmonary
disease, lung cancer status post right pneumonectomy in
[**2175-1-26**] complicated by a pulmonary artery laceration,
status post transtracheal catheter placement for oxygen and
suctioning. He was in his usual state of health until
[**2177-11-24**] when he developed nausea, lower abdominal
pain, projectile vomiting of nonbloody emesis. His
hematocrit dropped from 31 to a nadir of 13. His
gastrointestinal workup was unrevealing in the Medical
Intensive Care Unit.
1. Anemia secondary to acute blood loss - The patient's
gastrointestinal workup included two
esophagogastroduodenoscopies and colonoscopy times one
without source of frank bleed. However, in light of his
initial complaints of nausea, abdominal pain, and guaiac
positive stool a gastrointestinal source was still suspected.
Physically the small bowel could be the source. After
stabilization in the Medical Intensive Care Unit with blood
products, fresh frozen plasma and platelets, he was
transferred to the Medicine Floor after having stable
hematocrit for greater than 24 hours. While on the floor,
his hematocrit was checked initially every 12 hours. After
demonstrating stability for a total of 72 hours it was spaced
out to q. day hematocrit checks. All told the patient
received 7 units of packed red blood cells, 7 units of fresh
frozen plasma and one unit of platelets during his hospital
stay. On [**2177-12-3**], the patient underwent repeat
esophagogastroduodenoscopy in order to obtain biopsy samples
of the esophageal nodule, not noted on previous study. At
the time of this dictation results of those biopsies were
pending. While in the Medical Intensive Care Unit the
patient also had workup for hemolysis to evaluate whether
hemolysis could be attributing to his anemia. He had a
normal left ventricular hypertrophy, haptoglobin and
bilirubin on admission, however, making hemolysis a very
unlikely explanation for his presentation hematocrit of 19.
Moreover, no schistocytes were seen on peripheral smear.
Hemolysis laboratory data were checked several days into his
hospital course and were consistent with changes status post
large volume transfusion with no evidence of active ongoing
hemolysis.
2. Right upper extremity deep vein thrombosis - On [**2177-11-28**] the patient began to complain of right upper
extremity pain and swelling. Doppler ultrasound demonstrated
an axillary deep vein thrombosis. In light of his recent
bleeding episode, anticoagulation was held initially.
Although upper extremity deep vein thromboses do not embolize
as often as lower extremity deep vein thromboses, there was
still a very high concern for pulmonary embolus in light of
the patient's history of right pneumonectomy and the
functionality of his one remaining lung. The computerized
tomography scan was performed to better examine the right
upper extremity soft tissues. In particular there was
concern that the patient might have an obstructing mass
lesion or fibrosis-post his pneumonectomy that could be
contributing to venous stasis and obstruction leading to deep
vein thrombosis formation. Computerized tomographic venogram
was without evidence of obstructing lesion of fibrosis,
however. The patient is likely hypercoagulable as evidenced
by the development of this right upper extremity deep vein
thrombosis spontaneously after being off anticoagulation in
the setting of his acute bleed for only several days, there
was concern for recurrent deep vein thromboses. Therefore,
an inferior vena cava filter was placed on [**2177-12-2**].
The patient tolerated the procedure well. On [**2177-12-4**], the patient then began to complain of pain and swelling
of the right lower extremity. Examination was consistent
with possible thrombus of the right lower extremity.
However, as the patient already had an inferior vena cava
filter placed and delineation of a right lower extremity deep
vein thrombosis would not change management plans at all, the
decision was made not to undergo ultrasound doppler imaging
of the right lower extremity. In light of his probable
hypercoagulability, decision was made to reinitiate
anticoagulation with the Coumadin. His Coumadin level will
be followed by his outpatient physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
His INR should be checked remotely at the rehabilitation
facility and his Coumadin dose adjusted accordingly for a
goal INR of 2 to 3.
3. Chronic obstructive pulmonary disease/lung carcinoma
status post right pneumonectomy - The patient was continued
on aggressive regimen of chest physical therapy and pulmonary
toilet. He was continued on his outpatient medicines,
Combivent, Salmeterol, and Theophylline. He was continued on
antibiotic prophylaxis with Bactrim Double Strength in light
of his history of bronchiectasis. He was monitored for acute
decompensation and his respiratory status, particularly
concerning for pulmonary embolism in light of his right upper
extremity deep vein thrombosis. He continued to improve from
a respiratory standpoint. He was diuresed gently after
arriving to the Medicine Floor status post fluid
resuscitation and blood product administration in the Medical
Intensive Care Unit in the setting of his acute bleed. With
the diuresis, pulmonary toilet and supportive care, his
respiratory status improved somewhat. However, he is not
back to his baseline of 2 liters of oxygen nasal cannula at
home. At the time of discharge he was maintaining
saturations in the 97 to 100% range on 4 liters but he
continued to complain of increased dyspnea with activity and
shortness of breath, occasionally at rest. It was felt that
a lot the patient's dyspnea was secondary to muscle
deconditioning due to his prolonged illness and hospital
stay. Therefore he will be discharged to a pulmonary
rehabilitation program in hopes of increasing his
conditioning and improving his overall pulmonary status.
4. Diabetes mellitus 2 - The patient was maintained on a
diabetic diet, with q.i.d. fingersticks, fingerstick blood
glucose testing and coverage with a regular insulin sliding
scale. He was maintained on his outpatient dose of Neurontin
for neuropathy.
5. Atrial fibrillation - He was continued on his outpatient
dose of Amiodarone. Of note, he is currently in sinus
rhythm.
6. Acute renal failure - The patient on admission had an
elevated creatinine level above his baseline. This was
likely secondary to prerenal causes, specifically hypovolemia
and intravascular volume depletion in the setting of his
acute bleeding episode. His acute renal failure resolved
after fluid hydration.
7. Vitamin B12 deficiency - The patient was continued on his
outpatient regimen of supplementation with Vitamin B12, 1000
mcg p.o. b.i.d.
8. Hypercholesterolemia - The patient was continued on his
outpatient dose of Lipitor 10 mg p.o. q.d.
9. Depression/anxiety - The patient was continued on his
outpatient dose of Paroxetine 20 mg p.o. q.d.
10. Fluids, electrolytes and nutrition - The patient was fed
a diabetic heart-healthy diet. He received supplementation
with multivitamins and Vitamin B12. Electrolytes were
aggressively repleted. At the time of discharge he was
tolerating regular diet without nausea, vomiting or other
incident.
DISPOSITION: With the patient's general deconditioning as
well as his pulmonary status being slightly below his
baseline I felt that he would benefit from an inpatient
pulmonary rehabilitation program. He will be discharged to
such a program.
DISCHARGE CONDITION: Hemodynamically stable. Afebrile.
Oxygen saturation stable on 4 liters of nasal cannula,
ambulating independently, tolerating [**Last Name (NamePattern1) 243**] intake without
nausea or vomiting.
DISCHARGE STATUS: The patient is discharged to an extended
care facility.
DISCHARGE DIAGNOSIS:
1. Anemia due to acute blood loss, likely secondary to
gastrointestinal bleed.
2. Chronic obstructive pulmonary disease
3. Lung carcinoma, status post right pneumonectomy
4. History of perioperative pulmonary embolism
5. Atrial fibrillation
6. Hypertension
7. Diabetes mellitus 2, insulin requiring with neuropathy
8. Gastroesophageal reflux disease
9. Status post transtracheal catheter placement and oxygen
suctioning
10. Cataract
11. Anxiety
12. History of transient ischemic attack
13. Interrupted sleep apnea
14. Hypercholesterolemia
15. B12 deficiency
16. Right upper extremity deep vein thrombosis
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. q.d.
2. Regular insulin sliding scale
3. Atrovent nebulizer q. 6 hours as needed
4. Lasix 80 mg p.o. b.i.d.
5. Pantoprazole 40 mg p.o. q.d.
6. Gabapentin 100 mg p.o. q.d.
7. Paroxetine 20 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Glyburide 5 mg p.o. q.d.
10. Vitamin B12 1000 mcg p.o. b.i.d.
11. Lipitor 10 mg p.o. q.d.
12. Scopolamine 1.5 mg transdermal patch one patch q. 72
hours as needed
13. Salmeterol discus q. 12 hours
14. Senna two tablets p.o. b.i.d.
15. Percocet 1 to 2 tablets p.o. q. 4-6 hours as needed for
pain
16. Combivent 1 to 2 puffs inhaled q. 6 hours
17. Bactrim Double Strength one tablet p.o. b.i.d., last dose
to be given on [**2177-11-28**]
18. Morphine Sulfate elixir 5 to 10 mg p.o. q. 4-6 hours as
needed for pain, shortness of breath
19. Dulcolax 10 mg p.o. q.d. as needed for constipation
20. Ambien 5 to 10 mg p.o. q.h.s. as needed for insomnia
21. Multivitamin p.o. q.d.
22. Theophylline 400 mg sustained release 0.5 tablets p.o.
q.d.
23. Albuterol nebulizer solution one nebulizer inhaled q. 6
hours as needed for shortness of breath
24. Ativan 0.5 mg one tablet p.o. q. 4-6 hours as needed for
anxiety
25. Lactulose 30 ml p.o. q. 8 hours as needed for
constipation
26. Nystatin suspension 5 mg p.o. q.i.d. as needed for [**Year (4 digits) 243**]
thrush
FOLLOW UP PLANS: The patient has a scheduled follow up
appointment with Dr. [**Last Name (STitle) **] after discharge from the
rehabilitation facility. He will decide on the timing and
the necessity of any further testing or studies that will be
required including any further gastrointestinal workup for
bleeding. He will follow up on the biopsy results from the
patient's last esophagogastroduodenoscopy. The patient
should have his INR level checked daily while at the
rehabilitation facility and his Coumadin dose adjusted
appropriately with goal INR of 2.0 to 3.0.
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2177-12-4**] 20:17
T: [**2177-12-4**] 21:42
JOB#: [**Job Number 258**]
ICD9 Codes: 2765, 5849, 496, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4761
} | Medical Text: Admission Date: [**2131-6-2**] Discharge Date: [**2131-6-5**]
Date of Birth: [**2075-9-18**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 55-year-old female
with a past medical history of pulmonary sarcoidosis
diagnosed by chest CT and diabetes mellitus who presented to
[**Hospital3 **] with a left scapular and left arm pain since
1 a.m. on the day of admission. The painful episode was
triggered by emotional stress and physical activity. The
patient had a similar episode five days ago which resolved
spontaneously. Patient was having 5/10 chest pain on
presentation. Mrs. [**Known lastname 958**] denied chest pain, chest tightness,
no cough, shortness of breath, nausea and vomiting upon
presentation. The patient had no history of paroxysmal
nocturnal dyspnea orthopnea. In the [**Hospital1 **] Emergency Room,
the patient had an anterior lateral lead ST elevation and CK
elevation minimally to 45. Patient got oxygen, three 5 mg
doses of Lopressor, two 162 mg doses of aspirin and started
on heparin and nitrodrip. The patient was then transferred
to [**Hospital6 256**] and taken to
catheterization laboratory.
Catheterization laboratory showed a normal left main with a
twin left anterior descending system with 50-60% ostial
proximal stenosis, 100% mid stenosis after D1, D1 diffuse 80%
proximal with distally graftable lumen, left circumflex
40-50% mid lesion before the large OM1 and mild luminal
irregularities in the right coronary artery with a 100%
distal mid after posterolateral branch with TIMI II flow.
The culprit left anterior descending lesion was Hepacoat
stented with 0% residual and TIMI III distal flow, proximal
ostial 60%. Left anterior descending was not stented
secondary to ostial location involvement of D1.
PAST MEDICAL HISTORY:
1. Sarcoidosis, mild pulmonary involvement.
2. Noninsulin dependent diabetes mellitus for 15 years.
3. Blindness secondary to diabetic retinopathy.
ALLERGIES: Penicillin and novocaine.
MEDICATIONS AT HOME: Accupril, Lopressor, Amaryl and
Glucophage.
PHYSICAL EXAMINATION: Her Emergency Room vitals:
Temperature 97.9. Pulse is 97. Respiratory rate 18. Blood
pressure 196/110, saturating 98% on room air. Physical
examination: Alert and oriented times three in no acute
distress, lethargic, obese female. Head, eyes, ears, nose
and throat: She had bilateral submandibular gland
enlargement. Pupils equal, round and reactive to light.
Extraocular movements were intact. Oropharynx was clear.
She had a slight amount of dry blood was noticed on her lips
but there was no evidence of oral syringeal or tongue wax,
otherwise, she was normocephalic and atraumatic. The patient
had thinning hair density in a symmetric pattern. Her neck
exam: There is no carotid bruit. No thyromegaly. No
lymphadenopathy. No jugular venous pressure. Her
cardiovascular exam: Regular rate, no murmurs, rubs or
gallops, normal S1, normal S2. Possible S4 with distant
heart sounds. Pulmonary exam is clear to auscultation
bilaterally. No wheezes. Abdominal exam: Nontender,
positive active bowel sounds, obese, but not distended
abdomen. Extremities: Trace edema, 2+ posterior tibial
pulses bilaterally. Skin exam: Flank and extensor
dermatitis was noted. Her pre catheterization pain free
electrocardiogram showed a regular rate and rhythm, ST
elevation in V1 to V6 without reciprocal changes in I and
aVL. Her post catheterization electrocardiogram showed sinus
rhythm, left axis deviation, left anterior fascicular block,
anterior myocardial infarction based on Q waves development,
acute and recent. Only difference from the previous tracing
were the ST changes were less prominent.
HOSPITAL COURSE:
1. Cardiovascular:
A. Coronary artery disease: Patient's left anterior
descending was stented, however, the patient continued to
have a high risk coronary anatomy with persistent stenosis as
noted above. The prospects of coronary artery bypass graft
were discussed with the patient to be done within four to six
weeks. Patient was started on aspirin, Plavix times 30 days
and Integrilin times 18 hours, Lopressor, Lipitor and
captopril. A heparin drip was initiated to prophylax for
potential left ventricular thrombus in the setting of an
anterolateral left ventricular wall infarct, however, the
patient was taken off heparin when it was determined that her
risks were low given the results of her echocardiogram,
status post catheterization, which showed reasonably good
ejection fraction and no apical akinesis or dyskinesis, just
hypokinesis, which could not significantly increase the risk
for left ventricular thrombus formation.
B. Pump: Echocardiogram was checked while the patient was
hospitalized after her catheterization. The results showed a
mildly dilated left atrium, moderate symmetric left
ventricular hypertrophy with left ventricular cavity size
being normal. Overall, left ventricular systolic function
was mildly depressed with septal, distal, anterior and apical
hypokinesis. There was mild 1+ mitral regurgitation. The
patient's ejection fraction was estimated to be 40-45%.
C. Rhythm: The patient was normal sinus rhythm throughout
her hospitalization. Electrocardiogram showed no rhythm
abnormalities and no evidence of arrhythmia throughout her
hospitalization.
2. Pulmonary: The patient saturated well in the high 90s on
room air throughout her hospitalization.
3. Renal: The patient had no renal issues throughout her
hospitalization. Her BUN and creatinine remained stable
despite a heavy dye load in the catheterization. Intravenous
fluids were administered without dextrose per post
catheterization protocol to minimize the chance of dye
induced nephropathy. The patient was given a cardiac and
diabetic diet throughout her hospitalization. She was not
given her oral hypoglycemics and was covered with a sliding
scale insulin. Patient was instructed to restart oral
hypoglycemic regimen after discharge. We did not attenuate
her oral hypoglycemic regimen as this should be done on an
outpatient basis.
4. Hematology: Patient's hematocrit remained stable. Post
catheterization, she was checked daily for evidence of
pseudoaneurysm or hematoma at the catheterization site.
Patient had no evidence of hematoma or pseudoaneurysm at the
catheterization site.
FOLLOW-UP: The patient was seen by the Cardiothoracic
Surgery Service who spoke with her about potential
revascularization via coronary artery bypass grafting. This
decision was agreed upon by all parties including Coronary
Care Unit Team and the Cardiothoracic Surgery Team. The
Cardiothoracic Surgery Team was to contact the patient after
she was discharged to arrange surgery, which will be the best
long-term option for patient with significant coronary artery
disease with high risk anatomy in the setting of diabetes
mellitus.
DISCHARGE CONDITION: The patient was discharged in good
condition and she was discharged home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Myocardial infarction.
3. Diabetes mellitus.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-749
Dictated By:[**Last Name (NamePattern1) 98060**]
MEDQUIST36
D: [**2131-6-11**] 10:44
T: [**2131-6-11**] 10:44
JOB#: [**Job Number **]
ICD9 Codes: 2875, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4762
} | Medical Text: Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-6**]
Date of Birth: [**2054-3-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
cerebellar mass, chest pain after fall
Major Surgical or Invasive Procedure:
Chest tube placement, Lung biopsy
History of Present Illness:
78 yo M with PMH of HTN, HLD, Dementia, Aortic stenosis and
DM who presented to the ED after having a fall in the
bathtub. He was brought to the ED where he was found
to have a R cerebellar lesion and a cervical fracture. He also
had rib fractures and a R pneumothorax. A chest tube was placed
and he the lung re-expanded. He was intubated and taken to MRI
which showed a R cerebellar mass with edema and mass effect on
the peduncle, however no compression of the lateral ventricle.
Past Medical History:
Dementia, type unclear
Hypoglycemia
Diabetes mellitus for 15 years, insulin dependent
Hypertension
Hyperlipidemia
Severe aortic stenosis
Glaucoma -legally blind
Unable to see light out of the right eye
Able to count fingers with the left eye
BPH
Poor hearing bilaterally
Probably peripheral vascular disease
Social History:
Tob x 64 yrs, currently [**11-19**] PPD. Occas EtOH. Prev math professor
in [**Country 532**]. Immigrated to US in [**2124**].
.
- Son, [**Name (NI) 2491**]: [**Telephone/Fax (1) 71674**]
- Wife, [**Name (NI) 440**]: [**Telephone/Fax (1) 71675**]
- PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71676**]: [**Telephone/Fax (1) 35279**]
Family History:
Non-contributory
Physical Exam:
O: T: AF BP: 142/62 HR: 72 R 16 O2Sats 98% on ET
Gen: thin, intubated and sedated
HEENT: ET tube in place
Lungs: CTA on L, decreased breath sound on R
Cardiac: nl S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
MS: intubated, sedated
Cranial Nerves:
I: Not tested
II: Pupils: R opacified lense, L surgical
III, IV, VI: no oculocephalic
V, VII: face grossly symmetric.
VIII: untestable
IX, X: untestable
[**Doctor First Name 81**]: untestable
XII: untestable
Motor: withdraws symmetrically in all extremities
Sensation: as above
Reflexes: bilateral B 0 T 0 Br 0 Pa 0 Ac 0
toes bilaterally
Coordination: NA
Pertinent Results:
[**2133-2-27**] 05:00AM PT-12.1 PTT-25.8 INR(PT)-1.0
[**2133-2-27**] 05:00AM PLT SMR-NORMAL PLT COUNT-249
[**2133-2-27**] 05:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2133-2-27**] 05:00AM NEUTS-85.0* BANDS-0 LYMPHS-8.8* MONOS-4.6
EOS-1.4 BASOS-0.2
[**2133-2-27**] 05:00AM WBC-13.1* RBC-3.67* HGB-11.0* HCT-33.5*
MCV-92 MCH-30.0 MCHC-32.8 RDW-15.1
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: w/ & w/o gadolidium ?cva
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
78 year old man s/p fall in bathtub, ? cva based on CT
REASON FOR THIS EXAMINATION:
w/ & w/o gadolidium ?cva
CONTRAINDICATIONS for IV CONTRAST: None.
MRI OF THE HEAD WITH AND WITHOUT CONTRAST, MRA OF THE BRAIN. MRA
OF THE CAROTID AND VERTEBRAL ARTERIES (NECK MRA).
CLINICAL INDICATION: 78-year-old man status post fall in the
bathtub? Rule out CVA based on prior CT.
COMPARISON: Prior CT of the head dated [**2133-2-27**].
MRI OF THE BRAIN.
TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images
were obtained, axial T2, magnetic susceptibility, axial FLAIR,
diffusion-weighted sequences. The T1-weighted images were
repeated after the intravenous administration of gadolinium
contrast.
FINDINGS: In comparison with the prior CT, there is evidence of
vasogenic edema involving the right cerebellar hemisphere, In
addition, there is a rounded heterogeneously enhancing mass at
the level of the right cerebellar tonsil and posterior to the
right flocculus, the inferior limit of this lesion is adjacent
to the right side of the medulla oblongata, in the axial view,
this mass measures approximately 16 x 19 mm x 20 x 21 mm in the
coronal view by 18 x 20 mm in the sagittal projection. There is
no evidence of hydrocephalus. The pattern of enhancement in this
lesion is slightly heterogeneous with areas of low signal. There
is mild deviation of the right tonsil to the left. Therefore,
this lesion possibly is extra-axial, however, there is no
evidence of large dural attachment. No diffusion abnormalities
are noted. The supratentorial structures demonstrate an area of
cystic encephalomalacia posterior to the left caudate nucleus as
well as multiple lacunar ischemic events involving the basal
ganglia bilaterally. No other areas with abnormal enhancement
are visualized. Significant mucosal thickening is observed on
the right side of the ethmoidal air cells, with possible medial
wall deformity on the right. Lamina papyracea fluid level is
identified on the left maxillary sinus, associated with
significant mucosal thickening, there is also mucosal thickening
on the right maxillary sinus and in the medial aspect of the
frontal sinus, significant amount of secretion is identified in
the nasopharynx.
IMPRESSION:
1. Evidence of neoplastic process located on the inferior aspect
of the right cerebellar hemisphere, producing mass effect on the
right cerebellar tonsil, this lesion possibly is extra-axial,
however, is not completely clear given the pattern of edema and
enhancement. The differential diagnosis includes meningioma
versus metastatic lesion producing significant edema seen on the
right cerebellar hemisphere as described above. There is no
evidence of acute ischemic changes. Multiple lacunar ischemic
events are noted on the basal ganglia and posterior to the left
caudate nucleus. Maxillary sinusitis and ethmoidal mucosal
thickening. Small lacunar ischemic event is noted on the left
cerebellar hemisphere.
MRA OF THE CIRCLE OF [**Location (un) **]:
TECHNIQUE: Three-dimensional time-of-flight arteriography was
performed with rotational reconstructions.
COMPARISON: None.
There is evidence of vascular flow in both internal carotids as
well as the vertebrobasilar system. There is evidence of mild
atherosclerotic changes on the V4 segment of the left vertebral
artery vs mass effect. The anterior and middle cerebral arteries
appears patent without evidence of stenosis, there is no
evidence of aneurysms.
IMPRESSION: Mild narrowing of the V4 segment of the left
vertebral artery, likely representing atherosclerotic changes vs
mass effect, there is no evidence of other areas of stenosis in
the circle of [**Location (un) 431**] or aneurysm formation.
MRA OF THE CAROTID AND VERTEBRAL ARTERIES (NECK MRA).
TECHNIQUE: Two-dimensional time-of-flight MRA was performed,
coronal VIBE imaging was performed during infusion of
intravenous contrast, rotational reformatted images were
obtained.
COMPARISON: None.
FINDINGS: There is evidence of vascular flow in both common
carotids, mild- to-moderate stenosis is identified at the origin
of both internal carotids, correlation with ultrasound is
recommended if clinically warranted, both proximal vertebral
arteries are patent.
IMPRESSION: There is possible moderate stenosis at the origin of
both internal carotids in the cervical bifurcations, correlation
with carotid Doppler ultrasound is recommended if clinically
warranted.
CT ABD W&W/O C [**2133-2-27**] 8:01 PM
CT CHEST W/CONTRAST; CT ABD W&W/O C
Reason: Primary tumor?
Field of view: 34 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
78 year old man s/p fall with cerebellar tumor
REASON FOR THIS EXAMINATION:
Primary tumor?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old man status post fall. Findings
concerning for cerebellar tumor.
COMPARISON: Chest radiograph from [**2133-2-27**].
TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis
was performed after oral and intravenous contrast. Non-contrast
images of the abdomen and delayed images of the kidneys were
also obtained.
CT OF THE CHEST: An endotracheal tube is seen terminating in the
high trachea. Within the lung in the right upper lobe, there is
a 1.7 x 3.0 cm mass which extends along the bronchial tree
towards the hilum. Within the paratracheal region in the AP
window, subcarinal region, and in both hila, there are
necrotic-appearing lymph nodes in conglomeration. In the
paratracheal region they measure up to 14 mm, in the subcarinal
region they measure up to 18 mm. There are also small
prevascular lymph nodes which have the same appearance.
Elsewhere in the lungs, there are several other pulmonary
nodules, including on images 3:10, 30, 31, 39, 52, and 32. A
nasogastric tube extends into the stomach. The heart size is not
enlarged. There is a small amount of pericardial fluid. There is
extensive aortic valve calcification as well as coronary artery
and mitral annular calcification. The thoracic aorta is heavily
calcified throughout.
There is a right-sided chest tube in place, which terminates in
the posterior region of the hemithorax. A small
hydropneumothorax remains on the right. Several minimally
displaced rib fractures on the right are also noted with
subcutaneous emphysema.
CT OF THE ABDOMEN: The liver, gallbladder, right adrenal gland,
spleen, and pancreas appear unremarkable. There is a
hypoattenuating 15 mm left adrenal lesion.
Both kidneys contain cysts. The one on the left is too small to
characterize. Loops of small and large bowel demonstrate no
evidence of obstruction. There is a large amount of stool,
particularly in the right colon. There is no extraluminal air.
There is no ascites. There is heavy calcification of the
abdominal aorta without aneurysmal dilation.
CT OF THE PELVIS: There is a Foley catheter within the bladder
lumen. The rectum appears unremarkable. There is no free fluid.
There is no lymphadenopathy.
OSSEOUS STRUCTURES: There is a compression deformity of the L2
vertebral body, age indeterminate. Confluent anterior
osteophytes are noted.
IMPRESSION:
1. Lung mass in the right upper lobe with several other
pulmonary nodules bilaterally as above. Extensive medial and
hilar lymphadenopathy. Left adrenal lesion. All these findings
are highly suspicious for metastatic lung cancer.
2. Multiple right-sided rib fractures with small right
hydropneumothorax. Chest tube in place.
3. Compression deformity of the L2 vertebral body.
Brief Hospital Course:
The patient was admitted to the ICU from the ER intubated with a
chest tube. An MRI revealed a cerebellar mass and the patient
was transferred to the NSU service. Subsequently a CT of the
torso was obtained which showed a lung mass. This was biopsied
by interventional pulmonology and the pathology was consistent
with non-small cell lung cancer. A cardiology consult was
obtained due to his severe AS and they stated he would be very
high risk for surgery with AVR. This was discussed with the
family and the decision was made to not biopsy his cerebellar
mass and instead focus on his traumatic injuries. The chest tube
was managed by the trauma service. It was placed to water seal
on [**3-3**] but a repeat CXR showed the lung had fallen and the tube
was placed back on suction. On [**3-5**] it was placed back to
waterseal and the lung was stable for 24 hours. The CT was
removed on [**3-5**]. The patient remained intubated throughout his
hospital stay, failing numerous breathing trials. On the evening
of [**3-5**] he became hypotensive (40/P), hypothermic and mottled on
maximum dose of neo. The family was called to the bedside and
the decision was made to withhold further vasopressors and to
initiate a morphine drip.
Medications on Admission:
Isosorbide mg daily
Actos 15mg daily
Detrol 4mg daily
Aricept 10mg daily
Lisinopril 5mg daily
Lipitor 10mg daily
Aspirin 81mg daily
Toprol 25mg daily
Ativan 0.5mg daily
Senna
Humalog (75/25)
22 units qam
2 units qpm
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4763
} | Medical Text: Admission Date: [**2140-5-23**] Discharge Date: [**2140-6-10**]
Date of Birth: [**2079-5-1**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Multiple complaints--fall from height.
Major Surgical or Invasive Procedure:
ORIF left femur
ORIF ZMC
Anterior/posterior cervical decompression and fusion C4-7
History of Present Illness:
61M s/p 25 foot fall from roof with left
subtrochanteric/proximal femur femur fx, no LOC, per report, pt
was found awake on the ground, incontinent, complaining of
chest/LLE/R shoulder pain, seen at OSH, B/L chest tubes placed
for rib fx, intubated during transport for combativeness
Past Medical History:
autoimmune thyroiditis, depression, anemia, GERD
Social History:
Lives with wife
Family History:
N/C
Physical Exam:
Uncomfortable; multi trauma
Facial ecchymosis
RRR
Multiple rib fractures; + TTP
Abd soft NT/ND
femur splinted with obvious deformity
Pertinent Results:
[**2140-6-8**] 02:32AM BLOOD WBC-8.4 RBC-3.31* Hgb-9.6* Hct-28.6*
MCV-86 MCH-29.1 MCHC-33.7 RDW-15.5 Plt Ct-479*
[**2140-6-7**] 05:02PM BLOOD WBC-8.8 RBC-2.80* Hgb-8.1* Hct-24.0*
MCV-86 MCH-28.9 MCHC-33.6 RDW-15.3 Plt Ct-516*
[**2140-6-4**] 05:04AM BLOOD WBC-7.7 RBC-2.99* Hgb-8.4* Hct-26.1*
MCV-87 MCH-28.1 MCHC-32.3 RDW-15.6* Plt Ct-457*
[**2140-6-3**] 05:03AM BLOOD WBC-9.8 RBC-3.03* Hgb-8.7* Hct-26.6*
MCV-88 MCH-28.6 MCHC-32.6 RDW-16.0* Plt Ct-388
[**2140-5-31**] 06:38AM BLOOD WBC-6.7 RBC-2.92* Hgb-8.5* Hct-25.3*
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.7* Plt Ct-264
[**2140-5-30**] 07:10AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.8* Hct-27.0*
MCV-87 MCH-28.4 MCHC-32.4 RDW-15.4 Plt Ct-311
[**2140-6-8**] 02:32AM BLOOD Plt Ct-479*
[**2140-6-7**] 05:02PM BLOOD Plt Ct-516*
[**2140-6-6**] 08:22PM BLOOD Plt Ct-674*
[**2140-6-8**] 02:32AM BLOOD Glucose-155* UreaN-14 Creat-0.7 Na-139
K-4.5 Cl-105 HCO3-28 AnGap-11
[**2140-6-7**] 05:02PM BLOOD Glucose-133* UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-27 AnGap-12
[**2140-5-31**] 06:38AM BLOOD Glucose-121* UreaN-20 Creat-0.6 Na-136
K-4.1 Cl-102 HCO3-29 AnGap-9
[**2140-5-29**] 05:11PM BLOOD Glucose-180* UreaN-25* Creat-0.7 Na-138
K-3.3 Cl-104 HCO3-25 AnGap-12
[**2140-6-2**] 06:01AM BLOOD ALT-68* AST-51* AlkPhos-169* TotBili-1.9*
DirBili-0.7* IndBili-1.2
[**2140-5-31**] 06:38AM BLOOD ALT-94* AST-78* LD(LDH)-291* AlkPhos-192*
TotBili-1.6*
[**2140-5-29**] 01:32AM BLOOD ALT-85* AST-97* TotBili-3.8* DirBili-2.7*
IndBili-1.1
[**2140-6-8**] 02:32AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
[**2140-5-31**] 06:38AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0
[**2140-5-29**] 05:11PM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
Brief Hospital Course:
He was admitted to the Trauma Service. Plastics, Orthopedics and
Spine Surgery were consulted. On [**5-24**] Orthopedics repaired his
left intertrochanteric and left femoral shaft fracture. He was
taken back to the operating room on [**5-25**] by Plastics for repair
of his right zygomaticomaxillary complex malar fracture. An
Ophthalmology consult was requested by Plastics pre-operatively
to determine if any globe abnormalities and non were identified.
The Acute Pain Service was consulted for paravertebral catheter.
He had significant pain control issues which did improve over
the course of his stay with several adjustments in his doses.
Orthopedic Spine surgery was consulted for cervical stenosis and
spondylosis; discussions with patient and family took place. The
decision was made for operative repair; he was taken to the
operating room for a circumfrential cervical decompression and
fusion.
He was evaluated by Physical and Occupational therapy and is
being recommended for rehab after his acute rehab stay.
Medications on Admission:
Synthroid
Escitalopram
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-6**]
Drops Ophthalmic Q1H (every hour) as needed for eye irritation.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
14. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation QID (4 times a day).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours).
17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
18. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
21. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-6**]
Drops Ophthalmic Q1H (every hour) as needed for eye irritation.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
14. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation QID (4 times a day).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours).
17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
18. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
21. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Left subtrochanteric/proximal femur femur fracture
Multiple rib fractures
Multiple facial fractures
Cervical stenosis and spondylosis
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Cervical Decompression With Fusion; ORIF left femur; ORIF facial
fracture repair
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Cervical collar: when OOB
Treatment Frequency:
Please continue to change the dressings daily.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP Orthopedic
Trauma; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Dr. [**First Name (STitle) **], Plastic Surgery; call
[**Telephone/Fax (1) 5343**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for
evaluation of your rib fractures. Call [**Telephone/Fax (1) 79542**] for an
appointment. You will need to have a standing end expiratory
chest xray for this appointment.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in his clinic in 2 weeks. Call
[**Telephone/Fax (1) **] for an appointment
Completed by:[**2140-6-10**]
ICD9 Codes: 2761, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4764
} | Medical Text: Admission Date: [**2111-7-23**] Discharge Dates:
From NICU [**2111-7-27**]
From hospital [**2111-7-28**]
Date of Birth: [**2111-7-23**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 518**] [**Known lastname **] is the
former 3.83 kg product of a 37 week gestation pregnancy, born
to a 28-year-old GIV PI-II woman. Prenatal screens: Blood
surface antigen negative, group beta strep status unknown.
Maternal history notable for Type 1 diabetes treated with
insulin, also chronic hypertension treated with Aldomet and
Verapamil. The pregnancy was unremarkable. There was a
normal fetal echocardiogram performed. The infant was born
by repeat cesarean section. He was noted to have increased
respiratory rate at 15 minutes of age. Initial whole blood
Care Unit for treatment of hypoglycemia.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight 3.83 kg, length 50 cm, head
circumference 36 cm. Head, eyes, ears, nose and throat:
Anterior fontanel open and flat, no cleft lip, palate intact.
Cardiovascular: Regular rate and rhythm, soft systolic
murmur Grade II heard best at left lower sternal border.
Single second sound, pulses equal and full, +2 femoral
pulses. Lungs clear, no retractions. Abdomen slightly
distended but soft, bowel sounds present. Normal external
male genitalia, normal tone.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Known lastname 518**] remained in room air, with oxygen
saturations greater than 96% throughout the admission. The
initial tachypnea resolved within the first 12 hours after
birth.
2. Cardiovascular; Murmur noted upon admission persisted
through day of life two. A chest x-ray was within normal
limits, as were four limb blood pressures. The murmur had
disappeared by day of life number four.
3. Fluids, electrolytes and nutrition: [**Known lastname 518**] required
intravenous glucose administration to maintain adequate serum
glucoses. Enteral feeds were started on day of life number
one, and were well tolerated. Two calories of Polycose were
added to the formula to facilitate weaning of the intravenous
dextrose solutions. At the time of transfer to the newborn
nursery on day 4, he was ad lib by mouth feeding Enfamil 20 with
glucose of 66 to 78. Weight at the time of transfer was 3.625
kg. He continued to feed well in the newborn nursery until
discharge.
4. Infectious Disease: The CBC and blood culture were done
upon admission to the Neonatal Intensive Care Unit. The
white count was 13,000, with a differential of 66% polys, 0%
bands. No antibiotic treatment was initiated.
5. Gastrointestinal: Peak serum bilirubin occurred on day
of life number four, with a total of 17.9 mg/dl and 0.4 mg/dl
direct. Phototherapy had been initiated on day of life
number three for a serum bilirubin of 16.4 total mg/dl and
0.7 direct. His rebound, off phototherapy on the day of
discharge (day 5) was 11.6 total.
6. Neurology: [**Known lastname 518**] has maintained a normal neurologic
examination, and there are no neurological concerns at the
time of transfer.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Discharged home with parents after one
more day on the Newborn Nursery under the care of the [**Location (un) 13248**]
Newborn service.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Location (un) 43079**], [**Location (un) 8242**].
Tel [**Telephone/Fax (1) 36268**].
CARE RECOMMENDATIONS:
1. Feedings: Enfamil 20 ad lib by mouth.
2. Medications: None.
3. State newborn screen was sent on day of life number
three, with no notification of abnormal results to date.
DISCHARGE DIAGNOSIS:
1. 37 weeks gestation
2. Hypoglycemia
3. Suspicion for sepsis ruled out
4. Unconjugated hyperbilirubinemia
5. Infant of a diabetic mother
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**]
Dictated By: [**First Name11 (Name Pattern1) 22866**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN MS [**Name13 (STitle) **]
Edited in proof by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] to provide addendum in
newborn nursery.
MEDQUIST36
D: [**2111-7-27**] 23:59
T: [**2111-7-28**] 00:55
JOB#: [**Job Number 43080**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4765
} | Medical Text: Admission Date: [**2116-7-25**] Discharge Date: [**2116-7-28**]
Date of Birth: [**2077-2-1**] Sex: F
Service: MEDICINE
Allergies:
Pentostatin / Iodine; Iodine Containing / Linezolid
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Hypotension, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 92191**] is a 39 year-old female with a history of NHL T-cell
status post mini-allo-MUD BMT in [**12/2114**] complicated by grade 1
skin GVHD now in remission, off CSA since [**6-/2115**], Prednisone
[**2-/2116**], and Cellcept [**4-/2116**], who presents from the ED with
hypotension, and fever.
*
She was recently evaluated in the Hem/[**Hospital **] clinic and a restaging
PET scan was worrisome for two new bilateral foci of increased
FDG uptake in the neck raising suspicion for recurrent FDG-avid
lymphoma. She was therefore scheduled for a CT neck with
contrast today for further evaluation. She pressented for her CT
scan to [**Hospital1 18**], and underwent the study uneventfully. Following
the procedure, she ate a hamburger with mayonnaise from the
cafeteria, and walked home. When she arrived, she developed
vague diffuse abdominal pain, then watery diarrhea X 3-4 times.
She also endorses N/V, with emesis X multiple times. Around the
same time, she also noted a new pruritic rash inside both her
ankles, which susbsequently resolved. She called EMS, who came
to her house, but for an unclear reason felt that she did not
require further care. She subsequently presented to the ED for
further evaluation. + chills and subjective fever, + flushing.
Mild dry cough over past few days. She reports a [**12-20**]-week
history of urinary frequency, no dysuria. ? Cloudy urine in past
week, with right-sided back pain. Urine culture from [**7-22**]
(hem/onc clinic) contaminated. No recent travel, no other
unusual food. She lives in a boarding home, may have been in
contact with other sick people.
*
In the ED, her initial vitals were T 104.2, HR 147, BP 91/39, RR
18, Sat 98% RA. She was hydrated with 6.5 L NS, and given
Vancomycin 1gm, Levofloxacin 500 mg IV, and Cefepime 2gm IV. She
was also given HC 100 mg IV, and Benadryl 25 mg IV. Her blood
pressure improved with the above therapy. A right IJ triple
lumen was placed in sterile conditions. She is being admitted
for further care.
Past Medical History:
1. Non-Hodgkin's T cell lymphoma, diagnosed in [**1-/2113**], s/p
Rituximab with disease progression, s/p CHOP with evidence of
progression after 3rd cycle, s/p Pentostatin, Rituxan c/b TTP,
s/p mini-allo-MUD BMT in [**12/2114**] complicated by grade 1 skin
GVHD, off CSA since [**6-/2115**], Prednisone since [**2-/2116**], Cellcept
06/[**2115**].
2. History of renal failure requiring HD secondary to CSA and
lymphomatous infiltration.
3. Hypercholesterolemia
4. Depression
5. Congenital abnormalities of the fingers, status post 2
surgical interventions.
6. Generalized arthralgias, followed by rheumatology, ?
fibromyalgia
7. Glaucoma
8. History of VRE UTI.
Social History:
She lives in a boarding home, with 40 other co-residents. They
share a kitchen and bathroom. She is a non-smoker. She currently
lives in the apartments. She denied use of tobacco or illicit
drugs. She no longer drinks alcohol but formerly used socially.
Family History:
Her sister died at the age of 22 of lymphomatoid granulomatosis.
She also had CNS lymphoma. Her father died of CLL after marrow
transplantation for aplastic anemia at 62. Her mother died of
stroke at the age of 65.
Physical Exam:
VITALS: T 98.9, BP 88/53, HR 94, RR 16, Sat 99% on 2L. CVP 10.
Last SvO2 84%.
GEN: In NAD.
HEENT: MMM. Anicteric. PERRL. Mild bilateral tonsillar
enlargement, with ? food residue versus exudate on right.
Oropharynx otherwise unremarkable.
NECK: No palpable cervical, axillary lymphadenopathy.
RESP: CTAB, without adventitious sounds.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: Obese abdomen. BS NA. Abdomen soft, non-tender. Mild right
CVA tenderness.
EXT: Without edema.
INTEGUMENT: No rash. No flushing.
Pertinent Results:
[**2116-7-24**] 08:30PM WBC-7.5 RBC-3.66* HGB-12.7 HCT-36.2 MCV-99*
MCH-34.6* MCHC-35.1* RDW-13.7
[**2116-7-24**] 08:30PM NEUTS-50 BANDS-48* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2116-7-24**] 08:30PM PLT COUNT-248
[**2116-7-24**] 08:30PM CORTISOL-35.0*
[**2116-7-24**] 08:30PM HAPTOGLOB-147
[**2116-7-24**] 08:30PM CALCIUM-9.2 PHOSPHATE-1.6*# MAGNESIUM-1.5*
[**2116-7-24**] 08:30PM LIPASE-65*
[**2116-7-24**] 08:30PM ALT(SGPT)-29 AST(SGOT)-22 LD(LDH)-152 ALK
PHOS-129* AMYLASE-91 TOT BILI-0.2
[**2116-7-24**] 08:30PM GLUCOSE-118* UREA N-18 CREAT-1.4* SODIUM-140
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-18
[**2116-7-24**] 08:48PM LACTATE-4.0*
[**2116-7-24**] 09:30PM FIBRINOGE-340
[**2116-7-24**] 09:30PM PT-11.6 PTT-21.6* INR(PT)-1.0
*
EKG in ED: Sinus tachycardia, rate 129 bpm, indeterminate axis,
old Qs in III, aVF, TW flattening in V2-6, no change versus
prior.
*
RELEVANT IMAGING DATA:
[**2116-7-24**] CXR portable: Again noted are staples from prior lung
wedge resection on the right. There are very low lung volumes.
No definite
consolidations are seen. There is platelike atelectasis at the
left lung base. The heart size is normal given technique. No
layering pleural effusions are seen.
*
[**2116-7-24**] CT NECK W/ contrast: No abnormally enlarged nodes in
the neck. The areas of increased uptake noted on PET scan could
correspond to the region of the tonsils, which appear
unremarkable on the CT scan. However, any interval change in
their size could not be assessed due to lack of prior comparable
studies.
*
[**2116-7-17**] PET SCAN: Two new bilateral foci of increased FDG
uptake in neck raising raising suspicion for recurrent FDG-avid
lymphoma. Other considerations would include granulomatous
processes and reactive lymphadenopathy. The intensity is greater
than usually seen but does not exclude reactive nodes. Recommend
correlation with history of any recent infectious symptoms.
Brief Hospital Course:
ASSESSMENT AND PLAN: 39 yo female with history of T-cell NHL in
remission with recent abnormal PET scan findings under further
investigation, with fever, hypotension of 12-hour duration,
responsive to IVF.
*
1) Fever, hypotension: Resolved after one night. Although her
presentation most suggestive of severe sepsis, with elevated
lactate and hypotension responsive to IVF resuscitation, the
rapid resolution was more consistent with an anaphylactic
reaction to IV contrast from the CT. Dr. [**Last Name (STitle) 410**] has reported a
similar admission where the patient presented with a septic
picture which subsequently resolved without localizing a source.
Sbe was treated with the sepsis protocol and broad-spectrum
antibiotic coverage with cefepime and levofloxacin.
Hydrocortisone was given in the emergency room, so [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim
test would have been useless.
*
2) T-cell NHL in remission: Recent PET findings were concerning
for disease recurrence, although CT neck without
lymphadenopathy. Her Acyclovir and Bactrim prophylaxis were both
continued. There were no active heme/onc issues during this
admission.
*
3) ARF: Creatinine up to 1.4 on admission, decreased to normal,
suspect pre-renal physiology given elevated specific gravity and
improvement with hydration.
Medications on Admission:
Acyclovir 400 mg PO TID
Bactrim DS 1 tab PO QD 3x/week
Protonix 40 mg PO QD
Folic acid 1 mg PO QD
Celexa 40 mg PO QD
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Zantac 150 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
7. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Likely anaphylactic reaction to contrast
Secondary: T-cell lymphoma
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
Please take all of your medications as prescribed. If you
experience any dizziness, fever, headache, nausea, vomiting,
rash, or other concerning symptoms, please seek medical
attention immediately. You have been prescribed Benadryl and
Zantac to take every 6 hours until your appointment with Dr.
[**First Name (STitle) **].
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Thursday [**7-30**].
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4766
} | Medical Text: Admission Date: [**2189-6-21**] Discharge Date: [**2189-6-29**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 15247**]
Chief Complaint:
Difficulty breathing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52 F with history of sarcoidosis complicated by prior airway
obstruction and chronic trach, DM1 and triopathy, CABG, HTN, MI,
morbid obesity, most recent discharge [**5-20**], here with SOB x half
day. SOB started gradually earlier this afternoon with vomiting,
diaphoresis, and with her usual migraine. In the ED, she was
noted to be 87% on RA with increased work of breathing, 97% on
10L trach mask. CXR LLL infiltrate, small L>R effusion. EKG
unchanged, cardiac enzymes negative, no CP, not like previous
MI. BNP 34. Has WBC 14.6, received levaquin and had local
erythema raised with pruritus so was switched to Ceftriaxone and
Azithromycin. Received 60 methylprednisolone, reglan, zofran,
morphine.
.
MICU course: Patient had urine culture grow pseudomonas, ddimer
was positive so they were planning on a CTA to be done before
transfer. Respiratory therapy reported that patient does have
thick secretions with trach suctioning. Patient reported pain
with coughing.
Past Medical History:
1. DM-TI - age 16 diagnosis (c/b neuropathy, gastroparesis)
2. Sarcodosis ([**2175**])
3. Tracheostomy - [**3-13**] upper airway obstruction, sarcoid.
4. Arthritis - wheel chair bound
5. Neurogenic bladder
6. Sleep apnea
7. Asthma
8. Hypertension
9. Cardiomyopathy - diastolic dysfunction
10. Pulmonary hypertension
11. Hyperlipidemia
12. CAD s/p CABG (SVG to OM1, OM2, and LIMA to LAD, cath [**2183**])
13. VRE, MRSA - unknown sources
14. s/p cholecystectomy
[**97**]. s/p appendectomy
16. Chronic low back pain
17. Morbid obesity
Social History:
Lives alone, has monogamous partner lives 15min away, denies
ethanol, tobacco use.
Family History:
No hx of CAD, diabetes in cousin and uncle
Father had MI in his 60s
Physical Exam:
98.9 / 100 / 18 / 155/83 / 97% on 14L 0.6 trach mask
GEN: Alert, oriented x3, obese, to speak patient covers the
opening of her trach.
HEENT: No scleral icterus, PERRL, OP dry and clear, trach with
no erythema/edema/secretions, no carotid bruits
LUNGS: Difficult to hear because of body habitus, but no rales
appreciated
HEART: RRR, no m/r/g, distant heart sounds
ABD: Soft, +BS, ND NT
EXTR: 2+ pitting edema bilaterally
NEURO: [**6-13**] motor
Pertinent Results:
Admission Labs [**2189-6-20**] 11:40PM :
GLUCOSE-135* UREA N-37* CREAT-1.2* SODIUM-140 POTASSIUM-3.9
CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2189-6-20**] 11:40PM CK(CPK)-89 CK-MB-4 cTropnT-<0.01 proBNP-1384*
WBC-14.6*# RBC-4.20 HGB-13.3 HCT-39.4 MCV-94 MCH-31.6 MCHC-33.7
RDW-14.2 PLT SMR-NORMAL PLT COUNT-184
NEUTS-90.2* BANDS-0 LYMPHS-7.7* MONOS-1.5* EOS-0.5 BASOS-0
.
PT-11.1 PTT-20.2* INR(PT)-0.9
.
[**2189-6-21**] 06:12AM URINE
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-OCC EPI-0-2
.
[**2189-6-21**] 07:28PM D-DIMER-1169*
.
[**2189-6-21**] 07:28PM CK(CPK)-292* CK-MB-13* MB INDX-4.5
cTropnT-0.12*
.
[**6-21**] CXR PA and lat:
1. Mild/moderate pulmonary edema
2. Patchy area of consolidation in left lower lobe - atelectasis
or pneumonia.
.
[**6-22**] bilateral lower ext u/s:
Very limited study secondary to patient body habitus. No
definite evidence of DVT is identified.
.
[**6-23**] CT chest/abd:
1. Bibasilar atelectasis and small bilateral pleural effusions.
2. Markedly limited examination due to patient's body habitus.
No definite stones seen within the renal collecting systems. No
evidence of hydronephrosis. Periumbilical hernia and small left
ventral wall hernia containing omental fat. No evidence of bowel
obstruction.
.
[**6-23**] Echo:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild
regional left ventricular systolic dysfunction with
inferior/inferolateral
akinesis/hypokinesis (however views are technically suboptimal
for assessment
of regional wall motion). Estimated left ventricular ejection
fraction ?55%.
Right ventricular chamber size and free wall motion are probably
normal. 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. No
mitral regurgitation is seen. There is no pericardial effusion.
No significant
aortic or mitral regurgitation is detected but views are
technically
suboptimal.
Brief Hospital Course:
52 F with history of sarcoidosis complicated by prior airway
obstruction and chronic trach, DM1 and triopathy, CABG, HTN, MI,
morbid obesity, most recent discharge [**5-20**], here with SOB which
is improved.
.
# SOB: Likely associated with acute on chronic underlying
restrictive defect, obesity hypoventilation, pulmonary
hypertension, and LLL infiltrate. She has not taken steroids PO
for her sarcoidosis in years. She completed a 5 day course of
azithromycin for Community acquired pneumonia. She will
complete a 10 day course of cefpodoxime for combo treatement of
CAP and complicated pseudomonas UTI. Case was discussed with
sleep/pulm and thought that she likely had nighttime hypoxia
secondary to obesity. We discharged her with home oxygen and
for a home overnight oximetry in 1 monthto evaluate and follow
up with Dr. [**Last Name (STitle) 575**].
.
# N/V: Patient was treated for constipation with good result.
She was treated for gastroparesis with return to home reglan
doses and antiemetics prn. On benzotropine for effects of
reglan.
.
# Cardiac:
Ischemia: NSTEMI on [**6-21**] by enzymes and ruled out on [**6-26**] for
nausea. She has history of CABG, MI. Case was discussed with
cardiologist, Dr. [**Last Name (STitle) **] on [**6-22**], and recommended medical
management; continued ASA, metoprolol (slightly lower dose than
admission) and statin. Echo was suboptimal.
Pump: Has diastolic dysfunction with EF 55%
.
# ARF: Cr improved with IVF. FeNa <1, c/w pre-renal azotemia.
Urine Eos + rash with levo possible AIN.
.
# UTI (complicated): patient has chronic indwelling foley and
pseudomonas in urine. Initially treated with ceftaz starting
[**6-23**] and transitioned to cefpodoxime to complete 10 day course.
.
# DM1: Has had since age 16. Patient is on glargine 64 QHS on
home regimen, started at 40 and increased to 60 day of discharge
and discharged on home regimen.
.
# Chronic pain and anxiety issues:
- On Vicodin, Ativan, and Fioricet.
.
FEN: No IVF, replete K/Mg, DM diet
PPX: PPI [**Hospital1 **], heparin sc
CODE: Full
Contact: partner, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 17063**]
Medications on Admission:
1. Celexa 20mg qd
2. Lopressor 25mg [**Hospital1 **]
3. Cozaar 25mg qd
4. Colace 100 [**Hospital1 **]
5. Multivitamin [**Hospital1 **]
6. Tums ultra 1000 [**Hospital1 **]
7. Zofran 8mg [**Hospital1 **] prn
8. Compazine 25mg prn, no more than [**Hospital1 **]
9. Nystop 100,000units per gram to affected area [**Hospital1 **]
10. Fiorcet - 325/40/50 (no more than 2 per day)
11. Aspirin 325 qd
12. Lipitor 10 qd
13. Hydrocodone-Acetaminophen 5-500mg prn
14. Salmeterol 21 mcg/Dose disk prn
15. Albuterol 90 mcg 1-2puffs [**Hospital1 **] prn
16. Prilosec 20mg qd
17. Fluticasone 110 mcg 2 puffs [**Hospital1 **]
18. Glargine - 64 qhs
19. Insulin - regular - sliding scale
20. Metoclopramide 10mg - 2 with breakfast, 1 with lunch, two
with dinner, 1 at dinner (increase to 20 qid when ill)
21. Gabapentin 600 qd
22. Lorazepam 1 mg [**Hospital1 **] prn
23. Mag oxide [**Hospital1 **]
24. Benztropine 1mg tid
25. Hctz 25 mg qd
26. Protonix 40 [**Hospital1 **]
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days: To be completed on [**7-6**] .
Disp:*28 Tablet(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
15. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
Disp:*22 Tablet(s)* Refills:*0*
16. Nystop 100,000 unit/g Powder Sig: One (1) Topical twice a
day: To affected area.
17. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every twelve (12) hours as needed for headache: No
more than 2 per day.
18. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
19. Continuous oxygen
Please use continuous oxygen via trach mask to maintain oxygen
saturations above 92%.
.
Please have the oxygen company do an overnight oximetry in 1
month for evaluation and send results to Dr. [**Last Name (STitle) 575**] at ([**Telephone/Fax (1) 514**].
20. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold while taking your antibiotics.
21. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-10**] Inhalation
twice a day.
22. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Metoclopramide 10 mg Tablet Sig: 1-2 Tablets PO QIDACHS (4
times a day (before meals and at bedtime)): On dosing schedule
of 20 QAM, 10 Qnoon, 20 QPM, 10 QHS. .
24. Insulin Glargine 100 unit/mL Solution Sig: Sixty Four (64)
units Subcutaneous at bedtime.
25. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig:
Variable units Subcutaneous four times a day: As per home
sliding scale.
26. Metamucil Powder Sig: One (1) packet PO twice a day as
needed for constipation.
Disp:*60 packets* Refills:*2*
27. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**2-10**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Community acquired pneumonia
Urinary tract infection
NSTEMI
Diabetes mellitus
Acute interstitial nephritis/acute renal failure
Sarcoidosis
Morbid obesity
Gastroparesis
Discharge Condition:
Stable, requiring oxygen.
Discharge Instructions:
You were admitted with a pneumonia. You also had a urinary
tract infection. You were treated with antibiotics for both of
these infections. You will continue on an oral antibiotic as an
outpatient until [**7-6**].
.
You had some difficulty breathing on admission, which was felt
to be due to multiple problems, including obesity, pulmonary
hypertension, and pneumonia. You continued to have low oxygen
saturations intermittently, so you will be discharged with
oxygen for you to use at home as needed.
.
You also had an NSTEMI on admission, which may have been due to
demand ischemia. You should continue on your aspirin, bblocker
(lopressor), statin (lipitor) and [**Last Name (un) **] (cozaar) for medical
management of your heart disease.
.
Please keep all your follow-up appointments.
.
Please take all your medications as prescribed.
1) You have a new antibiotic, cefpodoxime, which you should
continue taking until [**7-6**].
2) Your dose of metoprolol has been reduced to 12.5mg twice a
day. This dose should be titrated up as an outpatient.
3) You are NO LONGER taking hydrochlorothiazide.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
lightheadedness, dizziness, difficulty breathing, chest pain,
nausea, vomiting, inability to tolerate your oral medications,
or any other worrisome symptoms.
Followup Instructions:
Please keep the following appointments:
.
[**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2189-7-8**]
1:40
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-7-9**]
9:00
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2189-8-3**] 1:30
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2189-8-7**] 11:00am
.
[**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **], MD Phone [**Telephone/Fax (1) 612**] Date/Time: [**2189-8-25**] at
8AM (spirometry first at 8AM on [**Location (un) 436**], then appt at 8:30AM)
.
Dr.[**Name (NI) 15921**] office will be calling you with an appointment time
for a repeat pMIBI (stress test for your heart). If you have not
heard from her office by Friday, please call to confirm the date
of your test.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 15248**]
ICD9 Codes: 486, 4280, 5849, 5990, 4254, 3572, 4019, 4168, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4767
} | Medical Text: Admission Date: [**2153-9-2**] Discharge Date: [**2153-9-6**]
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Garbled speech, Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 87838**] is a [**Age over 90 **] year old woman with history of several
strokes, DM, CAD, and possible pAFib not on coumadin who
developed garbled speech and right sided weakness at her
[**Hospital3 **] facility.
.
She was in her usual state of health until she rang the call
button at her [**Hospital3 **] stating she was feeling poorly.
When help arrived, she was confused and unable to speak.
.
Upon arrival to the ED, initial VS were 102.4 97 176/95 23 100%
BS 147. Code stroke was called. She was noted to have right
sided weakness. Although she was initially aphasic, she was
later described as dysarthric during her time in the ED. Stat
MRI showed no diffusion abnormalities, so no tPA was given. The
stroke team felt that her symptoms were most likely due to
recrudescence in the setting of infection vs seizure activity at
her old stroke site. Of note, she received a dose of ativan
while the ED team was attempting to obtain an LP but they were
unable to get the LP because of intense rigors.
.
She received vancomycin and ceftriaxone. She had an episode of
brown bilious emesis for which she was given 4mg zofran; there
was concern for aspiration during the MRI ([**Name8 (MD) **] RN report, the
MRI was stopped early as she became cyanotic and was vomiting).
A total of 1300cc of IV fluids were given.
.
These symptoms were identical to her stroke in 5/[**2152**]. As
described in the excellent Neuro consult note:
"Of note, she also presented as a CODE STROKE to [**Hospital1 18**] on
[**2153-4-19**]
with similar symptoms of garbled speech, right sided weakness,
and left gaze preference. Her NIHSS was 17. Temp was 102 on
admission, but blood and urine culture showed no growth. CTP
showed area of abnormal perfusion in the left posterior cerebral
artery distribution with no definite vascular stenosis
identified
and no CT evidence of completed infarction. MRI/MRA showed no
evidence of acute ischemia or infarction in the left MCA
territory, major intracranial vessels including left MCA appear
patent on MRA. EEG showed intermittent brief bursts of moderate
amplitude mixed theta and delta frequency slowing in a
generalized distribution, no epileptiform features. She was seen
by Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in follow up on [**2153-6-26**], and was found to
have no residual limb weakness or numbness, but minor residual
language impairments."
Past Medical History:
Stroke--several in past, most recently [**4-12**] as described above
CAD s/p MI, has Cypher stent to RCA [**2148**]
TTE [**4-12**]: EF > 55%, [**12-6**]+MR, 3+TR
DM--diet controlled
HTN
? Paroxysmal AFib not on coumadin
Pancreatic cyst -- benign, appears to be enlarging. Followed
by Dr. [**First Name4 (NamePattern1) 2127**] [**Last Name (NamePattern1) 10113**] at [**Hospital1 18**].
R hydronephrosis [**1-6**] [**Month/Day (2) 96980**] obstruction (70% obstructed) -
Asymptomatic, urology following, recommend no intervention at
this time.
Systemic sclerosis -- diagnosed at young age. Has associated
Raynaud's, esophageal and intestinal dysmotility, interstitial
lung disease.
Sjogren's syndrome-- uses NS eyedrops
Squamous cell carcinoma of skin
Basal cell carcinoma -- 2 lesions removed
Interstitial lung disease
Osteoporosis
GERD/peptic ulcer disease
Macular degeneration -- legally blind, some sight in L eye
Cataracts
-h/o LE DVT but no known PE
.
PSH:
-Colectomy in her 40s d/t SBO, likely [**1-6**] dysmotility from
scleroderma
-TAH/RSO for menorrhagia at age 39
-appendectomy (age 20s)
-femoral hernia repair
Social History:
Lives at [**Location **] Place/[**Location (un) 55**] [**Telephone/Fax (1) 96982**]
Patient was a [**Hospital1 18**] employee x 36 years, widowed. She has 2
children, one in [**State **] and [**State 4565**]. She has 5
grandchildren and 11 great-grandchildren. She lives in [**Location **]
Place [**Hospital3 **] facility and is very satisfied with her
care there. She is able to dress herself and go to the BR
without assistance. She has meals delivered. She walks with a
cane during the day and with a walker at night. She is legally
blind [**1-6**] macular degeneration, and therefore cannot drive.
Tobacco: 15 pk-yr, quit 65 yrs ago No EtOH or drug use.
Family History:
Father died at 52 of MI
Mother died at 96 from stroke
One died at age 60 from cancer
She has two living sons, 69yo with macular degeneration and a
younger son (can't remember age) with DM, MD, and h/o MI
One grandchild died at young age from melanoma
Physical Exam:
103.6 98 183/97 20 100% RA
Very thin and wasted, able to orient to person's voice but makes
poor eye contact.
Awake but not alert, not oriented to time, place, or self.
Unable to follow commands or answer questions appropriately.
Speech garbled.
Pupils equal, round, reactive, intact consensual response.
Unable to track or to follow command to do so.
Minimal extraocular movements while observing room.
No blink to threat b/l. Unable to count fingers.
Face symmetric.
Kernig's and Brudzinski's negative, neck supple.
Heart is tachy but regular without any murmur.
Lungs clear b/l without wheeze.
Abd: +BS, soft and not tender. Not distended.
Neuro: 4/5 strength in LE b/l (unable to assess if [**4-9**]); at
least [**2-7**] in UE b/l but unable to assess if greater. DTRs: +3
throughout, symmetric. Tremor of hands with voluntary movement
b/l. Toes equivocal b/l.
Pertinent Results:
ADMISSION LABS:
[**2153-9-2**] 07:30PM
PT-12.6 PTT-22.9 INR(PT)-1.1
PLT COUNT-215
WBC-7.4 RBC-4.20 HGB-12.1 HCT-37.1 MCV-88 MCH-28.9 MCHC-32.7
RDW-16.8*
proBNP-5849*
LIPASE-51
ALT(SGPT)-24 AST(SGOT)-46* LD(LDH)-536* ALK PHOS-89 TOT BILI-0.7
GLUCOSE-141* UREA N-23* CREAT-1.6* SODIUM-136 POTASSIUM-5.6*
CHLORIDE-100 TOTAL CO2-27
URINE:
[**2153-9-2**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2153-9-2**] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
LACTATE
[**2153-9-2**] 11:22PM LACTATE-5.3*
[**2153-9-3**] 01:25PM BLOOD Lactate-2.8*
ARTERIAL:
[**2153-9-2**] 11:22PM ART TEMP-38.2 PO2-122* PCO2-31* PH-7.44 TOTAL
CO2-22
DISCHARGE LABS:
[**2153-9-6**] 07:00AM BLOOD WBC-8.6 RBC-4.19* Hgb-12.1 Hct-37.7
MCV-90 MCH-28.9 MCHC-32.1 RDW-16.1* Plt Ct-185
[**2153-9-6**] 07:00AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-142
K-3.9 Cl-103 HCO3-29
[**2153-9-6**] 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
WORK UP:
[**2153-9-3**] 01:38AM BLOOD %HbA1c-6.1*
[**2153-9-3**] 01:29AM BLOOD Triglyc-78 HDL-51 CHOL/HD-2.4 LDLcalc-53
CARDIAC ENZYMES:
[**2153-9-3**] 01:29AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-9-3**] 09:53AM BLOOD CK-MB-5 cTropnT-0.06*
[**2153-9-3**] 05:42PM BLOOD CK-MB-5 cTropnT-0.06*
[**2153-9-4**] 04:57AM BLOOD cTropnT-0.07*
[**2153-9-4**] 05:52PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2153-9-4**] 08:14PM BLOOD CK-MB-4 cTropnT-0.05*
[**2153-9-5**] 06:50AM BLOOD CK-MB-4 cTropnT-0.04*
[**9-4**] MRA NECK W/CONTRAST:
1. Carotid arteries appear normal.
2. The vertebral artery origins are not visualized on the right
and poorly
visualized on the left, which may be related to technical
limitations. The
remainder of the vertebral arteries are patent. However, a
high-grade stenosis at the right vertebral artery origin and a
mild stenosis at the left vertebral artery origin cannot be
excluded.
[**9-3**] CXR: In comparison with the study of [**9-2**], there is little
overall
change. Again there is enlargement of the cardiac silhouette
with diffuse
interstitial pattern that could reflect vascular congestion,
congestive
failure, or both. The interstitial changes would be consistent
with the
apparent patient history of scleroderma. Specifically, no acute
focal pneumonia.
[**9-3**] ECHO: The left atrium is moderately dilated. The right
atrium is markedly dilated. No atrial septal defect is seen by
2D or color Doppler. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%) (the conduction
defect, irregular rhythm, and RV pressure /volume overload make
ventricular septal systolic function difficult to assess). There
is no ventricular septal defect. The right ventricular cavity is
markedly dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2153-4-20**], the overall LVEF is probably less
vigorous.
EEG: This EEG gives evidence for a moderate to moderately severe
and diffuse encephalopathy with background slowing and relative
invariance to the rhythm itself. There does appear to be, on
occasion,
some isolated localization with relative suppression of
electrical
activity over the left lateral temporal and dorsilateral
prefrontal
region suggesting either diffuse cortical injury in that region
or the
possibility of interposed materials, for example, subdural
hematoma
fluid collection. No epileptiform activity was identified and
there is
a markedly abnormal cardiac rhythm present.
[**9-2**] MRI BRAIN w/o CONTRAST: The sagittal T1 and axial T2 images
are somewhat limited by patient motion. Within the limits of
this study, there is no evidence for hemorrhage, edema, mass
effect, masses, or infarction. The ventricles and sulci are
mildly enlarged, consistent with mild atrophy. Mild
periventricular white matter FLAIR hyperintensities are likely
secondary to small vessel ischemic disease. There is no
diffusion abnormality detected to suggest acute ischemia. There
are no abnormal susceptibility artifacts suggesting history of
hemorrhage. An isolated diffusion artifact (4. 10) is likely
secondary to air in the nearby sphenoid sinus. The major
vascular flow voids are unremarkable.
IMPRESSION: No evidence for acute ischemia. Mild parenchymal
atrophy and
sequelae of small vessel ischemic disease.
[**9-2**]: SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING PORT
Dentures are seen in situ. There is no radiopaque foreign body
within the soft tissues of the head, neck, chest or abdomen.
Extensive
degenerative change is present throughout the spine. There is
cardiomegaly
with background interstitial pulmonary fibrosis and bilateral
hilar
prominence, which may represent pulmonary artery enlargement
versus hilar
lymphadenopathy.
ECGs:
[**9-2**]:
Rate PR QRS QT/QTc P QRS T
86 148 88 382/427 57 -76 60
Sinus rhythm with atrial premature depolarizations. Left axis
deviation. Left anterior fascicular block. Inferior myocardial
infarction. Leftward percordial R wave transition point. Diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2153-7-27**] heart rate has increased. Multiple
other abnormalities as noted persist without major change.
TRACING #1
[**9-3**]:
Rate PR QRS QT/QTc P QRS T
71 140 94 460/479 21 -67 -38
Sinus rhythm with atrial premature beats. Left axis deviation.
Left anterior fascicular block. Slight ST segment elevation in
leads V1-V3 with T wave inversions in leads III, aVF and V1-V4
raising the question of ischemia. However, given the patient's
prior intraventricular conduction delay, T wave memory could
also explain the T wave inversions. Compared to the previous
tracing of [**2153-9-3**] a run of atrial tachycardia is no longer seen
and the intraventricular conduction delay has resolved.
[**9-4**]:
Rate PR QRS QT/QTc P QRS T
56 132 90 514/507 45 -70 -93
Sinus bradycardia. Inferior myocardial infarction. Anteroseptal
myocardial
infarction. Compared to the previous tracing of [**2153-9-3**]
precordial T wave
inversion is more pronounced. Otherwise, multiple abnormalities
persist
without major change.
TRACING #1
[**9-5**]:
Rate PR QRS QT/QTc P QRS T
59 134 92 496/494 32 -72 -70
Sinus bradycardia. Compared to the previous tracing multiple
abnormalities
as previously noted persist without major change.
TRACING #2
Brief Hospital Course:
[**Age over 90 **] year old female with a history of cerebral vascular accident
who presented with expressive aphasia, right sided weakness and
fevers.
1) Aphasia/R sided weakness/Altered Mental Status: Patient had
no new changes on MRI. Neurology evaluated the patient in detail
and felt that the symptoms were consistent with seizure. EEG
showed evidence of patient's prior stroke and activity that
could indicate a predisposition to seizure. Neurology
recommended and the patient was initiated on Keppra 250 mg [**Hospital1 **]
liquid. It is also possible that her symptoms were related to
her fevers, discussed below, which resolved for > 48 hours prior
to discharge. Speech, weakness, and mental status have improved
to near baseline at time of discharge. Patient's gait was
slightly off balance, as noted by physical therapy at time of
discharge, though on examination her cerebellar function was
intact and there were no findings on head MRI suggestive of
cerebellar insult. Likely gait can be attributed to patient
being deconditioned. Patient's antihypertensives were intially
held due to concern for stroke, but were restarted prior to
discharge as the patient did not have evidence of a new stroke.
Patient was continued on her aspirin and plavix throughout her
hospitalization.
2) Fever/Leukocytosis: Patient with fever to 102 and
leukocytosis to 16 on presentation that resolved within 24 hours
of admission. Patient had a witnessed aspiration event in the
Emergency Department and it was unclear if the patient had
aspirated at home. As mentioned above, neurology felt her
neurological symptoms may have been due to a seizure. Abdominal
and pelvic CT on [**9-4**] did not indicate an sources of infection.
Fever at presentation initially treated with doses of cefepime,
ceftriaxone and vancomycin over first 48 hours. Chest x-ray no
pneumonia, urine culture negative. Given patient's rapidly
recovery in mental status, and lack on menigismal signs at
presentation patient was not felt to have had an infectious
central process. Given no source for infection, the patient's
antibiotics were stopped and the patient remained afebrile with
no leukocytosis. Blood cultures all negative to date at time of
discharge. Fever and leukocytosis have been attributed to event
either viral infection or seizure.
3) Cardiac Enzymes: Patient troponins checked out of concern for
cardiac event in the setting of presentation with altered mental
status patient endorsed intermittent complaints of chest pain.
Patient with troponin trend of [**9-3**] <0.01--> 0.06. [**9-4**]
0.07-->0.06-->0.05. CK-MB normal. Unlikely to represent ongoing
ischemia since enzymes trending down. Patient did have T wave
inversions on ECG [**9-4**] of unclear significance. Patient without
hypertension, tachycardia, hypoxia. Patient continued to improve
in terms of mental status. Patient's cardiac troponins with mild
elevation that trended downward. Patient EKG remained stable
from [**9-4**] onward.
4) Coronary Artery Disease status post PCI: patient was
maintained on her aspirin, plavix, metoprolol and lipitor.
Patient was restarted on imdur as discharge due to no evidence
for stroke.
5) Paroxysmal Atrial Fibrillation: Patient currently not on
anticoagulation due to her multiple falls. Patient was
maintained on metoprolol for rate control. Patient to discuss
with her primary care provider [**Name Initial (PRE) 19824**]/benefits of coumadin.
Patient on aspirin 81mg and plavix currently.
6) Anxiety/Depression: Patient continued on her lexapro and
lorasepam prn.
7) Diabetes: Patient was maintained on an insulin sliding scale
for glucose control. Patient is a diet controlled diabetic at
home and sliding scale was not continued upon discharge.
8) Sjogren's Syndrome: Cont normal saline eye drops
9) Gastroesophageal reflux disease continued lansoprazole
10) Asthma continued albuterol nebs q6h:PRN wheezing
Patient was seen by speech and swallow and recommened for
regular solids, nectar/thickened liquids, medications/pills with
nectar/thickened liquids
Patient was DNR/DNI during this hospitalization. Disposition to
acute care rehabilitation per physical therapy recommendations.
Medications on Admission:
ASA 81mg daily
Metoprolol 25mg [**Hospital1 **]
Imdur 180mg daily
Plavix 75mg daily
Lipitor 10mg daily
NTG SL PRN
Ativan 0.5mg prn
Clonazepam 0.25mg [**Hospital1 **]
Lexapro 10mg daily
Prilosec 20mg daily
Fosamax 70mg weekly
Tums 300mg [**Hospital1 **]
Tylenol 500mg [**Hospital1 **] PRN
Vitamin D 1000 units daily
Colace 100mg prn
Albuterol
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Imdur 60 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed.
8. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day: take twice a day with food.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for headache.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
14. Levetiracetam 100 mg/mL Solution Sig: 250 mg PO BID (2
times a day).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-6**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
18. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: Altered mental status
Secondary: Atrial Fibrillation, Hypertension, Coronary Artery
Disease
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital becuase you had right sided
weakness and were having difficulty speaking. In the emergency
department you were found to have a fever and given IV
antibiotics. Your mental status improved while in the emergency
department and during your time in the intensive care unit. Your
fever also resolved during the rest of your admission. You were
seen by the neurology team who felt that given your symtpoms on
presentation combined with results of a brain test called an EEG
you may have had a seizure. The neurologists did not feel that
you had a stroke.
We have added a new medication to your regimen called Keppra to
prevent seizures. This medication should be taken twice per day.
Neurology would like to follow up with you in one month.
If you experience chest pain, shortness of breath, significant
weakness of any part of your body or difficulty speaking please
come to the emergency department for further evaluation.
Followup Instructions:
PROVIDER (PCP): [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2153-9-19**] 8:40
Provider (Neurology): [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2153-10-8**] 1:00
Completed by:[**2153-9-8**]
ICD9 Codes: 5849, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4768
} | Medical Text: Admission Date: [**2127-6-17**] Discharge Date: [**2127-7-11**]
Date of Birth: [**2090-12-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p motorbike injury
LLE diarticulation
Major Surgical or Invasive Procedure:
[**6-17**]: L leg amputation, diagnostic peritoneal lavage, exploratory
laparotomy, L arm operative debridement
[**6-19**]: ORIF L SI joint & acetabular fracture
[**6-25**]: LUE STSG x2, closure of LLE amputation with skin flap
History of Present Illness:
36F s/p unhelmeted MVC motorbike vs car collision, with obvious
L leg fracture at site of accident. She presented to [**Hospital 8641**]
Hospital in hypovolemic shock, received 6 units of PRBC and was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
unknown
Social History:
HCP: [**Name (NI) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 61578**], work [**Telephone/Fax (1) 61579**]
Family History:
unknown
Physical Exam:
Temp 96, pulse 110, BP 80/40
Intubated, sedated
Tachy, CTA B
Soft NT, negative DPL
LUE with multiple abrasions, palp pulses
LLE grossly deformed with large laceration near amputation at
hip. No distal cap refill
Pertinent Results:
Please refer to carevue for specific lab data. On discharge:
[**2127-7-8**] 03:00AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.1* Hct-25.9*
MCV-88 MCH-27.7 MCHC-31.5 RDW-15.1 Plt Ct-909*
[**2127-7-6**] 03:17AM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1
[**2127-7-8**] 03:00AM BLOOD Glucose-91 UreaN-7 Creat-0.3* Na-137
K-4.7 Cl-103 HCO3-28 AnGap-11
[**2127-7-7**] 01:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2127-7-7**] 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.0 Leuks-MOD
[**2127-7-7**] 01:35PM URINE RBC-0-2 WBC-21-50* Bacteri-MOD Yeast-MOD
Epi-0
[**7-7**] CXR: 1) Lines and tubes in stable position. 2) No
significant interval change in patchy opacities within the
medial aspect of the right upper and left lower lung fields,
findings that likely relate to atelectasis. No definite evidence
of pneumonia.
[**7-3**] ANGIO: Successful placement of a retrievable Bard Recovery
nitinol IVC filter with the tip in an infrarenal position.
[**6-29**] MR spine: No evidence of abnormal vertebral body or
ligamentous signal seen in the cervical region. Small disc
herniation at C5-6 level slightly indenting the thecal sac. No
evidence of extrinsic spinal cord compression or intrinsic
spinal cord signal abnormalities.
[**6-29**] MR [**First Name (Titles) **] [**Last Name (Titles) **] evidence of acute infarct.
Brief Hospital Course:
Admitted from [**Hospital 8641**] Hospital. Taken emergently to OR by trauma
surgery/ortho/vascular. Please refer to previously dictated op
notes, which state that L lower extremity was not viable and was
disarticulated at the hip . Negative ex lap & debridement of
arm wounds. Admitted to SICU following OR. Please refer to
medical record for specifics of ICU course & interventions, but
brief synopsis of her current status follows.
NEURO: significant postop pain. treated with methadone & prn
oxycodone. IV meds DC'd once she was able to take meds via
dobhoff.
CARDS: stable
RESP: failed to wean off vent. Percutaneous tracheostomy placed
on [**7-3**].
FEN: Tubefeedings via dobhoff tolerated well. Refer to page 1
for details.
HEME: hematocrit relatively stable following initial operation.
ID: treating with kefzol for prophylaxis while JPs in place,
levaquin for UTI, fluconazole for fungal UTI.
PROPH: prevacid, SQ heparin, s/p IVC filter placement
MSK: s/p LLE amputation. wound infection vs dehiscence followed
by plastics. JP management per plastics team. treat with wet
to dry dressing packings. Plastics will follow in clinic in 1
week: call to schedule an appointment.
Medications on Admission:
unknown
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: [**1-12**] units
Injection ASDIR (AS DIRECTED): follow attached sliding scale.
Disp:*100 units* Refills:*2*
2. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
4 days: crush all meds.
Disp:*4 Tablet(s)* Refills:*0*
3. Keflex 250 mg/5 mL Suspension for Reconstitution Sig: Two (2)
teaspoons PO four times a day: while JP drains are in place.
Disp:*250 ML* Refills:*2*
4. Fluconazole 40 mg/mL Suspension for Reconstitution Sig: One
(1) teaspoon PO once a day for 1 weeks.
Disp:*100 ML* Refills:*2*
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ML Injection TID (3 times a day).
Disp:*90 ML* Refills:*2*
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily).
Disp:*30 dose* Refills:*2*
7. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): give separately from levaquin.
Disp:*30 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed: crush all pills.
Disp:*30 Tablet(s)* Refills:*2*
9. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day: or liquid alternative.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
10. Methadone 10 mg/5 mL Solution Sig: One (1) teaspoons PO
twice a day.
Disp:*300 ml* Refills:*2*
11. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons
PO BID (2 times a day) as needed.
Disp:*30 teaspoons* Refills:*0*
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Disp:*1 container* Refills:*0*
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
twice a day as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
15. Outpatient Lab Work
CBC, Chem-10 twice weekly
Discharge Disposition:
Extended Care
Facility:
northeast specialties [**Hospital1 **]
Discharge Diagnosis:
s/p motorbike accident
L femur disarticulation
circulatory arrest requiring CPR
T10-T11 spinous process fractures
R 4th rib fracture
lung contusion
comminuted L acetabular & pubic ramus fracture
large LUE abrasion s/p debridement
wound infection
urinary tract infection
postop atelectasis
hypokalemia
Discharge Condition:
improved
Discharge Instructions:
Tube feedings as tolerated. Meds via dobhoff tube. Wet to dry
dressing changes as directed.
Contact your MD if you develop any fevers > 101, increasing pain
or if there are any questions.
Followup Instructions:
Follow up at [**Hospital 3595**] clinic next Tuesday [**Telephone/Fax (1) 274**].
Follow up at Trauma clinic next Tuesday [**Telephone/Fax (1) 2359**].
Completed by:[**2127-7-8**]
ICD9 Codes: 5185, 4275, 2851, 5990, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4769
} | Medical Text: Admission Date: [**2143-4-8**] Discharge Date: [**2143-4-15**]
Service: ORTHOPAEDICS
Allergies:
Penicillins / Gentamicin / Bacitracin / Hydrochlorothiazide /
Chlorothiazide
Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
Right hip pain secondary to right femoral head AVN.
Major Surgical or Invasive Procedure:
[**Last Name (un) **] right DHS, revision Right Hip Replacement
History of Present Illness:
Ms. [**Known lastname **] is an 83 yo F w/PMHx sx for CLL, hypertension,
hyperlipidemia and depression who was admited for an elective
total hip arthroplasty for persistent low back and right hip
pain.
Past Medical History:
Chromic Lymphocytic Lymphoma
Hypertension
Hyperlipidemia
Depression
Osteoarthritis
Chronic low back and hip pain, avascular necrosis of right hip
Chronic bilateral knee pain
s/p right elbow fracture
s/p ORIF right hip [**2137**]
Peripheral Vascular Disease s/p bilat bypass grafts
Social History:
She currently lives alone. Denies any drug use. Quit smoking 15
years ago and only occasional alcohol use.
Family History:
n/a
Physical Exam:
Vitals: T: 98.7 BP 163/60 HR: 80 RR: 22 O2: 94% on 4L NC
Gen: elderly female, NAD, resting in bed
HEENT: NC, AT, MMM, OP clear
CV: RRR, no MRG
RESP: CTAB
ABD: soft, NT, ND, BS+
EXT: no edema, DP's 2+ bilat, able to wiggle toes
Pertinent Results:
[**2143-4-13**] 08:30AM BLOOD WBC-34.7* RBC-3.05* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.1 MCHC-33.3 RDW-16.2* Plt Ct-263
[**2143-4-12**] 10:30AM BLOOD WBC-39.9* RBC-2.96* Hgb-9.1* Hct-27.0*
MCV-91 MCH-30.6 MCHC-33.6 RDW-16.2* Plt Ct-225
[**2143-4-11**] 08:50AM BLOOD WBC-39.1* RBC-3.15* Hgb-9.9* Hct-27.5*
MCV-87 MCH-31.4 MCHC-36.0* RDW-16.5* Plt Ct-166
[**2143-4-10**] 11:40AM BLOOD WBC-53.4* RBC-3.35* Hgb-10.4* Hct-28.9*
MCV-86 MCH-30.9 MCHC-35.8* RDW-16.3* Plt Ct-171
[**2143-4-10**] 05:15AM BLOOD WBC-42.3*# RBC-3.32* Hgb-10.4* Hct-28.4*
MCV-86 MCH-31.2 MCHC-36.5* RDW-16.0* Plt Ct-155
[**2143-4-9**] 05:48PM BLOOD Hct-23.0*
[**2143-4-9**] 05:03AM BLOOD WBC-92.4* RBC-3.40* Hgb-10.6* Hct-29.5*
MCV-87 MCH-31.2 MCHC-36.1* RDW-16.1* Plt Ct-209
Brief Hospital Course:
A/P: Ms. [**Known lastname **] is an 83 yo F w/PMHx sx for HTN, hyperlipidemia,
PVD, and CLL who presents with hypotension in the setting of
right THR. Pt transferred to ICU for single recorded BP of 80/40
and intubated. Pt successfully extubated [**4-9**]. HCT did drop
while in ICU from 29.5 to 23, ortho was notified, patient
transfused 2 units with appropriate bump. No signs of active
bleeding. Lovenox held [**4-10**].
.
#. Respiratory failure. Patient was intubated electively for the
procedure. Had good oxygenation on 50% FiO2 and minimal PEEP.
Extubated successfully [**4-9**].
.
#. Hypotension. Probably [**3-16**] hypovolemia from blood loss in the
OR. Patient hypotensive briefly requiring pressors after 1200cc
blood loss in OR. s/p 6u pRBC in OR.
.
Acute Hematocrit drop - [**4-9**] HCT dropped from 29.5 to 23.
Asymptomatic, no signs of active bleeding, received 2 units
pRBCs with appropriate bump. Lovenox held on [**4-10**]. Hematocrit
stable at time of transfer to floor.
.
#. S/p Total hip replacment - tolerated procedure well. pain
controlled with Tylenol, Ultram and morphine.
Pt transferred from ICU to floor on [**4-10**]. PT consult requested.
AVSS HCT 28. Lovenox for anticoagulation. Pt remained stable and
screened for rehab placemment.
.
Medications on Admission:
Plavix 75 mg qd
Aspirin 325 mg qd
Fluvastatin
Trazadone 50 mg 1-2 tabs qde
Paroxetine 20 mg qd
Fosamax 70 mg qweek
Multivitamin
Calcium
Vitamin D
Darifenacin 7.5 mg qd
Furosemide 20 mg qd
Percocet prn
metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous DAILY (Daily) for 4 weeks.
15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
16. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QD ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right femoral head AVN
anemia
Discharge Condition:
good
Discharge Instructions:
activity as tolerated. Right lower extremity partial weight
bearing. Crutches/walker with ambulation. Lovenox for
anticoagulation. Pain meds as prescribed.
Physical Therapy:
Activity: Out of bed w/ assist
Right lower extremity: Partial weight bearing
Knee immobilizer: At all times
may remove KI while working with PT, troch off precautions,
posterior hip dislocation precautions
Treatments Frequency:
DSD QD
may leave incision open to air on [**2143-4-16**]
staples to be removed at f/u
Followup Instructions:
f/u with Dr[**Name (NI) 2989**] office in 2 weeks. Please call to make an
appt. [**Telephone/Fax (1) 20921**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**]
Completed by:[**2143-4-13**]
ICD9 Codes: 2851, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4770
} | Medical Text: Admission Date: [**2187-11-28**] Discharge Date: [**2187-11-30**]
Date of Birth: [**2119-12-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Back and Abdominal Pain
Major Surgical or Invasive Procedure:
[**2187-11-29**] - Attempte Repair of Ruptured Aortic Aneurysm
History of Present Illness:
67 y/o female with h/o aortic aneurysm who presented with 2-3
days of heart burn which was much worse today. The pain radiated
to her back and abdomen and she was intubated. A CT scan
revealed an aortic aneurysm without extravasation of contrast.
She was thus transferred to the [**Hospital1 18**] for further management.
Past Medical History:
Thoracic aortic aneurysm repair [**2182**]
Hyperlipidemia
HTN
COPD
PVD
PMR
Social History:
80 pack yr h/o smoking recently quitting.
Family History:
Parents both with cancer
Physical Exam:
SR 64 106/50 CVP 17
Intubated/sedated
Opens eyes to stimulation
LUNGS: Clear
HEART: RRR, no murmur
ABD: Obese, benign
EXT: 2+ PT pulses, no DP pulses felt, warm with good capillary
refill, no edema.
Pertinent Results:
[**2187-11-28**] 07:18PM PLT COUNT-187
[**2187-11-28**] 07:18PM WBC-16.6* RBC-3.94* HGB-10.8* HCT-34.6*
MCV-88 MCH-27.5 MCHC-31.3 RDW-17.0*
[**2187-11-28**] 07:18PM ALT(SGPT)-10 AST(SGOT)-17 CK(CPK)-22* ALK
PHOS-44 AMYLASE-31 TOT BILI-0.4
[**2187-11-28**] 07:18PM GLUCOSE-87 UREA N-23* CREAT-0.6 SODIUM-137
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-32 ANION GAP-11
[**2187-11-28**] 09:31PM GLUCOSE-80 UREA N-22* CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-34* ANION GAP-11
[**2187-11-28**] 09:31PM CALCIUM-8.6 PHOSPHATE-5.1* MAGNESIUM-2.2
[**2187-11-30**] 12:47AM BLOOD WBC-28.7* RBC-3.69* Hgb-11.4*# Hct-34.0*
MCV-92 MCH-30.8 MCHC-33.5 RDW-15.2 Plt Ct-71*#
[**2187-11-29**] ECHO
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium or left atrial appendage. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation.
The descending thoracic aorta is markedly dilated. The severe
dilatation
starts at the distal arch with what appears to be intramural
hematoma
superimposed upon severe atheromatous thickening of the media.
The intramural hematoma is almost circumferential with the
thickest portion measuring 1.6 cm in height in the anterior
aortic wall. The aneurysm measured 8cm in diameter at 35 cm from
the lip and 7cm x 6cm at 30 cm from the lip. An echogenic
density is seen at 35 cm, consistent with an intimal flap/aortic
dissection.
[**2187-11-30**] - ECHO
The patient came to the OR in extremis. She was resuscitated and
Fem-Carotid, and carotid-carotid grafts were done. The plan to
use endovascular grafts to repair the TAAA was aborted when the
femoral artery could not be accessed. The patient expired in the
OR.
We did have a chance to note that the large descending TAAA had
a great deal of clot around it, and that both ventricles were
compressed nearly completely. There was no AI and the ascending
aorta appeared normal. There was a small amount of MR, but there
was so little forward flow through the heart in spite of
inotropes and resuscitation with fluids and blood products, that
other measurements could not be done.
[**2187-11-28**] - CT Scan
1. No soft tissue stranding, circumferential fluid or contrast
extravasation from the repaired ascending aorta.
2. Large descending aortic aneurysm as described above. There is
no evidence of dissection flap, penetrating ulcer, or contrast
extravasation. A small left-sided pleural effusion is slightly
hyperdense without definite hematocrit level identified.
3. Aneurysmal right subclavian artery.
4. Right thyroid nodule as described above.
[**2187-11-29**] CXR
New pleural-based opacity extending over the upper aspect of the
left hemithorax with incomplete evaluation of the lateral lower
left chest as above. The presence of the new presumed loculated
effusion is worrisome given the presence of a known thoracic
aortic aneurysm. This may be indicative of rupture. [**First Name8 (NamePattern2) **]
[**Doctor Last Name **], nurse practitioner, was informed of these findings at
9:50 a.m. on [**2187-11-30**].
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2187-11-28**] for further
management of her aortic aneurysm. She was admitted to the ICU
and closely monitored. A TEE was performed which revealed a
dilated descending aorta with circumferential hematoma. There
was thought to be an area of dissection at the area which had a
protuberant atherosclerotic plaque. The cardiology service was
consulted for assistance given the likelihood of a high risk
reoperation. A chest x-ray on [**2187-11-29**] revealed a new loculated
effusion which was suggestive of an aortic rupture. Given these
findings, she was urgently taken to the operating room for
surgical management. All attempts were made by the cardiac
surgical service in conjunction with the vascular surgery
service to surgically repair her aneurysm however Ms. [**Known lastname **] [**Last Name (Titles) 69415**]d in the operating room at 1:39AM [**2187-11-30**].
Medications on Admission:
Aspirin 81mg QD
Lopressor 25mg QD
Lisinopril 5mg QD
Lasix 40mg QD
Zocor 20mg QD
Oxycodone
Combivent
Spiriva
Prednisone
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Ruptured Aortic Aneurysm
Discharge Condition:
Expired
Completed by:[**2187-12-19**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4771
} | Medical Text: Admission Date: [**2148-11-29**] Discharge Date: [**2148-12-8**]
Service: MEDICINE
Allergies:
Penicillins / Macrolide Antibiotics
Attending:[**First Name3 (LF) 20486**]
Chief Complaint:
Falls, bleeding per rectum
Major Surgical or Invasive Procedure:
Intubation
Right colic artery embolization (coil embolization)
History of Present Illness:
This is an 87 year old female with PMH of HTN, hyperlipidemia,
afib on Coumadin, h/o PE in [**2144**], h/o lacunar infarctions per
head CT in [**2142**], osteoporosis, h/o diverticulitis, internal and
external hemorrhoids, and multiple lower GI bleeds presenting
from an independent elderly living facility with one episode of
BRBPR last night, frequent falls over the last week with no
traumatic injury sustained, and found to be tachycardic to the
140s on admission. Reviewing recent clinic notes, it appears as
though the patient had been reporting recent abdominal cramping
and dizziness. She also mentions having dizziness and
diaphoresis with ambulation since yesterday.
.
In the ED, initial VS: T=98.1, HR=140, BP=137/84, RR=16, POx=98%
RA. Per report, her resting HR=110 and her HR would go up to
140s with movement. She appeared comfortable, but had lots of
dark blood in her rectal vault on exam. 2 PIVs in the form of a
16 gauge and 18 gauge were placed and she was given 1L IVFs. She
was also transfused 2 units of FFP, given vitamin K 10mg IV, and
an IV PPI. It was thought to be unlikely that this was an UGIB
so no NG lavage was performed. Her EKG looked like atrial
flutter versus sinus tachycardia. It was felt that no CT scan
was indicated for her multiple falls given that she had no pain
and adamantly denied hitting her head. Transfer vital signs were
T=98.1, HR=118, BP=168/80, RR=18, POx=100% RA.
.
ROS: No headache, fever, chill, jaundice, rash, muscle-joints
pain, no CP, SOB, cough, palpitation, no dysuria or urgency.
Past Medical History:
PAST MEDICAL HISTORY:
1. History of pulmonary embolism, [**2144**].
2. Hypertension.
3. Hypercholesterolemia.
4. Lacunar infarctions per head CT in [**2142**].
5. History of atrial fibrillation, followed by Dr. [**Last Name (STitle) 73**].
6. Osteoporosis.
7. History of diverticulitis and a history of gastrointestinal
bleeding.
8. Hearing loss.
9. Internal and external hemorrhoids.
PAST SURGICAL HISTORY:
1. Bilateral cataract surgery.
2. Removal of maxillary cyst at the [**Hospital6 54007**].
Social History:
Social History: The patient lives alone in her own apartment and
is single. She has many nieces and nephews who are involved in
her care.
Family History:
Two brothers died of lung cancer in their 70s and 80s. Mother
died in her 70s of heart disease. Father died in his 60s of
heart disease.
Physical Exam:
GEN: pleasant, comfortable, A+Ox3, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
jvd
RESP: CTAB with good air movement throughout
CV: tachycardic, difficult to appreciate any m/r/g
ABD: nd, +b/s, soft, nt
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: Per ED, large amount of guaiac positive dark blood in
rectal vault
Pertinent Results:
Admission labs:
[**2148-11-29**] 04:00PM PT-29.3* PTT-26.4 INR(PT)-2.9*
[**2148-11-29**] 04:00PM WBC-6.9# RBC-3.21* HGB-9.0* HCT-26.8* MCV-84
MCH-28.1 MCHC-33.6 RDW-15.5
[**2148-11-29**] 04:00PM GLUCOSE-131* UREA N-36* CREAT-1.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
Labs at discharge:
[**2148-12-2**] 09:20AM BLOOD WBC-7.8 RBC-3.83* Hgb-11.4* Hct-33.8*
MCV-88 MCH-29.9 MCHC-33.8 RDW-14.7 Plt Ct-126*
[**2148-12-2**] 09:20AM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-134
K-3.1* Cl-102 HCO3-26 AnGap-9
[**2148-12-2**] 09:20AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.6
Brief Hospital Course:
Mrs. [**Known lastname 7518**] is a 87 year old female with PMH of hypertension,
hyperlipidemia, afib on coumadin, pulmonary embolism ('[**44**]),
diverticulitis, internal and external hemorrhoids, and multiple
lower GI bleeds presenting with bright red bleeding per rectum
and frequent falls over the last week.
.
# Lower GI bleed: Upon arriving at the hospital, the patient was
tachycardic and, after admission into the ICU, passed clots and
large volume of bleeding per rectum. Coumadin was stopped, and
she was transfused with a total 8 units pRBC, 6 units FFP, and
one unit of platelets. The bleeding was likely a recurrent
diverticular bleed localized to the right colic artery, which
was embolized by interventional radiology on [**11-30**]. She required
intubation for airway protection and was extubated without
complications. On [**12-4**], her hct decreased to 25.2, prompting a
GI bleeding study that was unremarkable. Her hematocrit remained
stable (25 to 30) during the rest of her hospitalization, and
her anemia was treated with her home dose of ferrous Sulfate 325
mg. Her coumadin was restarted on [**12-6**]. At the time of
discharge, she was stable, and had a Hct of 29.4 and INR of 1.3.
.
# Bacteremia: On hospital day 3 ([**12-2**]), Mrs. [**Known lastname 7518**] developed
a fever and tachycardia to 120s. Blood cultures grew coagulase
positive S. aureus. The source of her infection was likely her
right internal jugular line. An echocardiogram on [**12-6**] showed
no vegetations on the valve leaflets, but moderate mitral and
tricuspid regurgitation consistent with a previous study
([**2147-8-29**]). She was treated with IV vancomycin for 4 days, and
transitioned to IV cefazolin for 6 weeks. At the time of
discharge, she was afebrile (98.1) and had no signs of sepsis. A
midline was placed instead of a PICC due to the fact that she
has a basilic vein clot, and she will need the midline changed
out every two weeks for as long as she requires IV antibiotics.
.
# Atrial fibrillation: She has a history of atrial fibrillation
requiring coumadin anticoagulation. During her hospitalization,
she was occasionally tachycardic to the 120s but remained
comfortable without chest pain or dyspnea. Telemetry and ECG
showed sinus rhythm with occasional atrial premature
contractions. She received rate control via Metoprolol. In the
setting of her fever and tachycardia, a chest CT was performed
to rule out a PE. Her coumadin 2mg was restarted on [**12-6**] after
stabilization of her Hct. There was a question of atrial flutter
on her EKG a few days before discharge due to HRs rising into
the 130s, but she was evaluated by EP using carotid maneuvers,
and the underlying rhythm was thought to be sinus tachycardia in
the setting of some dehydration. She was bolused with IVFs which
resulted in an improvement in her tachycardia down to 100s-110s
and her beta-blocker was increased to 37.5 mg PO TID at the time
of discharge. At the time of discharge, she was hemodynamically
stable and nonsymptomatic in the setting of the tachycardia,
with baseline in the low 100s-110s. Her INR at the time of
discharge was 1.2 and patient will need to have coumadin dosed
at rehab to get her back to her goal INR of [**2-28**].
.
# Hypertension: The patient has chronic hypertension. Blood
pressures at time of admission was 135/90. During her
hospitalization, her pressures were in the 140s/90s. She was
treated with Metoprolol 25 mg PO BID (twice her home dose), and
Losartan 25mg (normal home dose). Additional pharmacotherapy was
not initiated in anticipation of possible GI bleeding. At the
time of discharge, her BP was _.
.
# Falls: Pt presented with multiple falls for one week. During
her hospitalization, she has occasionally felt lightheaded upon
sitting or standing, however with moderate improvement through
her stay. She has received daily physical therapy, and is able
to ambulate with a walker. She was discharged to a
rehabilitation center due to the need for IV antibiotics, and
was ambulatory with assistance at the time of discharge.
.
# Hypercholestrolemia: Last cholesterol 171 in [**2148-1-26**]. She
was treated with her home dose of atorvastatin 20 mg at bedtime.
Medications on Admission:
-ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth once a day at night
-LOSARTAN [COZAAR] - 25 mg Tablet - 1 (One) Tablet(s) by mouth
every evening
-METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s)
by
mouth q 12 h
-WARFARIN [COUMADIN] - 2 mg Tablet - 1 (One) Tablet(s) by mouth
once a day; 3mg on Sundays
-CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 (One) Tablet(s) by mouth once a day
-DOCUSATE SODIUM - 100 mg Capsule - 1 (One) Capsule(s) by mouth
twice a day
-ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Capsule -
1
(One) Capsule(s) by mouth once a day
-FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 0.5 (One half)
Tablet(s) by mouth once a day
-SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 (One) Tablet(s) by
mouth
once to twice a day as needed for constipation
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. warfarin 2 mg Tablet Sig: One (1) Tablet PO M,T,W,THURS, F,
SAT ().
13. warfarin 1 mg Tablet Sig: Three (3) Tablet PO QSUN (every
Sunday).
14. cefazolin 10 gram Recon Soln Sig: Two (2) grams IV Injection
Q8H (every 8 hours) for 6 weeks.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
- Lower GI bleeding
Secondary:
- Atrial fibrillation
- Anemia
- Hypertension
- Hypercholestrolemia
Discharge Condition:
At the time of discharge, you were:
- Alert and fully oriented
- Clinically stable without active bleeding
- Ambulatory without assistance
Discharge Instructions:
You were seen in the hospital for multiple falls and an active
gastrointestinal bleed. In the ER, you received fresh frozen
plasma transfusion to control the bleeding, and, in the ICU,
received embolization of the bleeding right colic artery by
interventional radiology. You recovered well after the
procedure, and remained stable without active bleeding at the
time of discharge.
You were discharged on the following medications:
- Cefazolin 2mg IV every 8 hours.
- Metoprolol 25mg twice a day
- Atorvastatin 20mg one tablet at bedtime
- Losartan 25mg once a day
- Calcium Carbonate 200 mg (500 mg) Tablet twice a day
- Cholecalciferol (vitamin D3) 400 unit Tablet twice a day
- Ferrous Sulfate 300 mg (60 mg Iron) once a day
- Sennosides [SENOKOT] - 8.6 mg as needed for constipation
- Acetaminophen 325 mg Tablet Two (2) Tablets every 6 hours as
needed for pain.
- Docusate sodium 100 mg Capsule 2 times a day as needed for
constipation.
- Polyethylene glycol 3350 17 gram/dose Powder, one daily as
needed for constipation.
Followup Instructions:
Department: GERONTOLOGY
When: MONDAY [**2148-12-16**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: GASTROENTEROLOGY
When: TUESDAY [**2148-12-24**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2148-12-16**] 12:00
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2148-12-24**]
11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 20487**]
ICD9 Codes: 2851, 7907, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4772
} | Medical Text: Admission Date: [**2111-5-12**] Discharge Date: [**2111-5-18**]
Date of Birth: [**2052-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right loculated hydropneumothorax.
Major Surgical or Invasive Procedure:
[**2111-5-12**] Bronchoscopy, Right Thoracotomy, Decortication
History of Present Illness:
Mr. [**Known lastname 1968**] is a 59-year-old male with a history of recurrent
B-cell lymphoma and recurrent right-sided effusions. CT scan
suggested entrapped right lung
and loculated hydropneumothorax. It was felt that the patient
would need a decortication and would need open thoracotomy
versus VAT procedure.
Past Medical History:
CAD c/b MI x2 s/p PTCA/stent/CABG/AVR'[**97**],
Atrial fibrillations s/p pacemaker
RAS s/p renal stents x2,
Stage I Hodgkin's lymphoma s/p splenectomy & chemorad Rx to
chest/neck/abdomen,
B-cell lymphoma with pulmonary nodules s/p CHOP/CVP'[**03**],
Hypoetension, IDDM, Hypothyroidism, Upper GI bleed
Hypercholesterolemia, Renal Insufficiency
Social History:
Social: lives with wife, was a printer. Drinks ETOH
occasionally, does not smoke currently, was a 35ppy smoker.
Unknown asbestos exposure
Family History:
non-contributory
Physical Exam:
VS: 98.2 HR 60 BP 120/80 Sats 95% RA
General: 59 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: scattered rhonchi RLL, otherwise clear
GI: benign
Extr: warm no edema
Incision: Right thoracotomy site w/steri-strips clean dry intact
no erythema
Chest-tube sm-moderate serous drainage
Neuro: non-focal
Pertinent Results:
[**2111-5-17**] WBC-11.1* RBC-3.42* Hgb-9.6* Hct-29.8* Plt Ct-359
[**2111-5-12**] WBC-8.9 RBC-3.07* Hgb-8.2*# Hct-26.1* Plt Ct-341
[**2111-5-17**] Glucose-80 UreaN-35* Creat-1.3* Na-137 K-5.0 Cl-101
HCO3-28
[**2111-5-12**] Glucose-95 UreaN-23* Creat-1.5* Na-142 K-3.3 Cl-103
HCO3-28
[**2111-5-12**] URINE CULTURE (Final [**2111-5-13**]): NO GROWTH.
[**2111-5-12**] Blood cultures No Growth
[**2111-5-12**] 9:00 am PLEURAL FLUID ANTERIOR RIGHT.
GRAM STAIN (Final [**2111-5-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2111-5-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2111-5-18**]): NO GROWTH.
ACID FAST SMEAR (Final [**2111-5-13**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2111-5-12**]):
NO FUNGAL ELEMENTS SEEN.
CHEST (PA & LAT) [**2111-5-17**]
CHEST: The three chest tubes present on the prior ultrasound
have all been withdrawn. A localized hydropneumothorax is
present laterally in the mid zone. This was present before the
tubes removed. No significant pneumothorax is present.
IMPRESSION: Chest tubes removed. No significant pneumothorax.
Pleural cortex, right:
Fibroadipose tissue with chronic inflammation and granulation
tissue formation.
Clinical: Fibrothorax.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known firstname **] [**Known lastname 1968**]," the medical record number and "right pleural
cortex" and consists of multiple fragments of yellow fatty
tissue and tan pink granular appearing tissue that measure 13.5
x 12.5 x 4 cm in aggregate. The specimen is serially sliced to
reveal unremarkable cut surfaces. The specimen is represented
in A-B.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted on [**2111-5-12**] and underwent successful
Right thoracotomy, evacuation of right pleural effusion,
pleurectomy with decortication, flexible
bronchoscopy with therapeutic aspiration. He was transferred to
the SICU intubated, sedated on Propofol overnight. While in the
SICU his [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker was interrogated and found to be
within normal limits. The chest-tubes were to suction, his pain
was well controlled with a Bupivacaine & Dilaudid epidural
managed by the acute pain service. On POD #1 he was extubated
and his oxygen saturations were upper 90's on 2 Liters nasal
cannula and pulmonary toileting. On POD #2 he transferred to the
floor. The posterior chest-tube was removed, a regular diet was
initiated and he was resumed on his home medications. On POD #4
the epidural was removed and his pain was well controlled with a
Dilaudid PCA. The middle anterior chest tube was removed, his
foley was removed and he voided without difficulty. On POD #5
the remainder chest-tube was removed and his PCA was converted
to PO pain mediation. On POD #6 he continued to make steady
progress. He ambulated in the halls and was discharged to home.
He will follow-up with Dr.[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
levothyroine 137 mcg daily, toprol xl 50 mg daily, omeprazole 40
mg daily,
simvastatin 80 mg daily, glyburide 3.75 mg daily, aspirin 325 mg
daily, plavix 75 mg daily, amiodarone 200 mg Sun/Tues/[**Last Name (un) **]/Fri,
allopurinol 100 mg daily, furosemide 60 mg daily
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*70 Tablet(s)* Refills:*0*
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO as directed.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
CAD s/p MI s/p PTCA/stent/CABG/AVR [**2097**]
Atrial Fibrillation s/p Pacemaker
RAS s/p renal stents x 2
Hypertension/Hyperlipidemia
Hodgkin's Lymphoma s/p chemo/rad, s/p pulmonary nodules
Diabetes Mellitus Type 2, Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased cough or sputum production
-Chest pain
-Incision develops drainage or redness: steri-strips remove if
stop to peel off.
-Chest-tube site cover with a bandaid until healed. Should site
begin to drain cover with a clean dressings and change as needed
to keep site clean and dry
You may Shower: No tub bathing or swimming for 6 weeks
No driving while taking narcotics: take stool softners with
narcotics
Followup Instructions:
Follow-up with Dr.[**Doctor Last Name 4738**] NPs [**Female First Name (un) **] or [**Location (un) 1439**] on [**6-2**] at
1:00pm in the [**Hospital Ward Name 121**] Building Chest Disease Center, [**Hospital1 **] I
Report to the [**Location (un) 470**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**]
Completed by:[**2111-5-19**]
ICD9 Codes: 2449, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4773
} | Medical Text: Admission Date: [**2191-9-10**] Discharge Date: [**2191-9-15**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hemorrhage of LUE AVF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 y.o. M with ESRD on HD via LUE AVF presented to [**Hospital 4068**] Hosp
with hemorrhage of LUE AVF after dialysis.Gets HD at [**University/College **]
on a Mon and [**University/College 2974**] only schedule. Started using AVF about 2
weeks ago. Infiltrated at HD on [**Name6 (MD) 2974**] [**Name8 (MD) **] RN immediately took
needles out and used catheter. He was sent home. He noted some
bleeding at AVF, pain then felt diaphoretic and weak. EMS found
him with BP of 60/palp. Hypotensive with SBP in 60's, ptt >150.
He was given protamine/6L of NS/3 units of PRBC who developed a
large left anterior chest hematoma. EKG showed NSTEMI with a
troponin of 0.131. T waves were inverted anteriorly. He did not
have chest pain. Transferred to [**Hospital1 18**] SICU for close monitoring
on [**9-10**]. Admitted to SICU B with Hct 25.
Past Medical History:
PMH: CAD, Bladder CA, HTN, Renal Failure on HD via LUE AVF
PSH: Cystectomy 25 [**Last Name (un) **], CABG [**98**] [**Last Name (un) **], Corneal tx 8 [**Last Name (un) **], LAVF 3
mo ago
Social History:
lives with [**Age over 90 **] y.o. wife
Family History:
N/C
Physical Exam:
aaO x3, pale, NAD
RRR, no MRG
Rales on left side, right clear to auscultation. L chest wall
obviously expanded. tight chest skin. no active evidence of
expansion
soft, NT/ND/+BS
Lue stitch intact at small needle hole intact. severee
ecchymosis of LUE. palp thrill of avf, palp radial pulse. +
neuro exam throughout pin prick
Pertinent Results:
[**2191-9-15**] 06:50AM BLOOD WBC-8.6 RBC-3.00*# Hgb-9.3* Hct-27.8*
MCV-93 MCH-31.1 MCHC-33.6 RDW-18.5* Plt Ct-152
[**2191-9-14**] 06:10AM BLOOD WBC-9.0 RBC-2.39* Hgb-7.8* Hct-23.0*
MCV-96 MCH-32.6* MCHC-33.8 RDW-17.6* Plt Ct-151
[**2191-9-15**] 06:50AM BLOOD Glucose-87 UreaN-46* Creat-4.0* Na-140
K-3.9 Cl-102 HCO3-24 AnGap-18
[**2191-9-15**] 06:50AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.7
Brief Hospital Course:
He arrived via med flight to ED awake and alert. In ED noted to
have expanding hematoma tracking up arm from fistula into the
chest wall with a very large amt of blood in the chest wall. A
CT torso at [**Last Name (un) 4068**] was negative for aortic abnormality or
retroperitoneal bleed. Three liters of fluid and 2 units of PRBC
were given at [**Last Name (un) 4068**] then he received aother unit of PRBC here
at [**Hospital1 18**] as well as 2 units of FFP and a six pack of platelets.
A small needle hole was noted in AVF. A single stitch was placed
with hemostasis. HCT slowly trended down each day to 23.4 on
[**9-12**]. Epogen was given at dialysis. He was admitted to the SICU
for monitoring with serial hematocrits drawn. An U/S was done to
assess for active bleeding. This was a limited study due to
extensive hematoma. No pseudoaneurysm was visualized. His arm
was kept elevated. Tylenol was given for comfort. On [**8-14**], Hct
decreased to 23. He was transfused with 2 units of PRBC while in
hemodialsyis. Hemodialsyis was done via the R tunnelled HD line.
Upon admission, cardiac enzymes were cycled for previously noted
T wave changes. These were negative for MI. He was dialyzed via
the tunnelled HD line on [**9-12**] for 1.5 liters and again on [**9-14**].
Vital signs remained stable. The LUE arm circumference measured
12 inches with extensive bruising. Sensation was intact.
Diet was advanced and tolerated. Ileo conduit was draining well.
PT and OT evaluated him given that his wife reported that he had
fallen at home and that she was not strong enough to assist him
to get up. PT recommended rehab. He will be discharged to
[**Location (un) 582**] at [**Location (un) 620**], [**Telephone/Fax (1) 63378**].
Medications on Admission:
aspirin 81mg qd, zocor 80mg qd, niacin 500mg qd, lasix 20mg qd,
hctz 50mg qd, atenolol 50mg qd, felodipine 2.5mg qd, predforte
1% every other day
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO prn: 4 hours if
needed for pain as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
while taking percocet to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Niacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic every other day.
9. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
ESRD
Bleeding of LUE AVF
LUE/L chest hematoma
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if increased
swelling, bruising/bleeding of left arm/chest or if malfunction
of dialysis line
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2191-9-29**]
9:00
Completed by:[**2191-9-15**]
ICD9 Codes: 5856, 2851, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4774
} | Medical Text: Admission Date: [**2156-12-14**] Discharge Date: [**2156-12-16**]
Date of Birth: [**2070-4-13**] Sex: M
Service: MEDICINE
Allergies:
Fluoride
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ventricular tachycardia status-post ablation
Major Surgical or Invasive Procedure:
[**2156-12-14**] - Ablation of ventricular tachycardia
History of Present Illness:
86 year-old male with CAD who is s/p CABG x 5 in [**2156**]. He is followed by Dr. [**Last Name (STitle) 7047**] and
underwent a nuclear stress test in [**2155-7-20**]. This revealed a
severe fixed perfusion defect involving the inferior wall with a
mild degree of peri infarction ischemia. There was also a fixed
apical defect consistent with an old apical MI. There was
akinesis of the inferior wall and apex with severe hypokinesis
of the mid to distal anterior wall apex which is consistent with
multi-segmental CAD. The ejection fraction was 27%. He underwent
BiV ICD placement on [**2155-9-9**] for primary prevention of sudden
cardiac death. His course was complicated by a moderate
pneumothorax, he was asymptomatic, and an x-ray the following
day showed improvement of the pneumothorax and he was
discharged.
.
3-4 months ago he was pulling on a garden hose and he became
dizzy and saw "lights". He leaned against a wall and received a
shock from his ICD. He felt fine within a minute. He went to
[**Hospital3 417**] where he stayed there 3 days. He denies any
further testing or medication changes.
.
Two months ago he was driving and felt poorly and noted his
heart was "fluttering" he was able to drive home but had a near
syncopal episode and he felt his ICD fire. EMS was summoned and
he was found to be in VT at a rate of 140 bpm his ICD did not
fire as it was set for 170 bpm. Patient states he knows his ICD
fired prior getting to the hospital. He was externally
cardioverted. His amiodarone was increased to 400mg daily.
.
He denies any further fluttering or ICD shocks. When he is
resting he feels that he can feel his heart beating but denies
any palpitations. He does report his heart rate has been fast
and he has brief intermittent dizziness. His Amiodarone was
discontinued last week ([**2156-12-1**]) by Dr. [**Last Name (STitle) 17918**] as it was
thought to be ineffective.
.
He denies chest pain, and reports some dyspnea with exertion
along with mild dizziness if he gets up too quickly. He loses
his balance frequently from his neuropathy. He has not been able
to drive since his last ICD shock. He was referred for VT
ablation today.
.
During VT ablation, EP was able to induced 6 different VT in
lab, ablate along the scar in the inferior septum at the base on
LV. At the end of study, no longer able to induce any VT.
Bedrest for 6 hrs, continue carvedilol no antiarrythmic. In
procedure, he was 2L positive and got lasix 40 IV.
.
On arrival to CCU, he appears to be comfortable.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: CAD S/P CABG x 5 in [**2156**]
- PERCUTANEOUS CORONARY INTERVENTIONS: none documented
- PACING/ICD: Cardiomyopathy and LBBB s/p [**Company 1543**] Concerto
D274TRK BiV ICD [**2155-9-9**]
3. OTHER PAST MEDICAL HISTORY:
Severe neuropathy
Prostate enlargement
H. Pylori
Colon CA
Peripheral Neuropathy
TIA [**4-26**]
GERD
Hiatal Hernia
Diverticulosis
Actinic Keratosis
Ventral Hernia
Polio age 8
Depression
Weight Loss with negative CT scan
Social History:
He lives with his wife [**Name (NI) **]. [**Name2 (NI) **] has six children. He was an
electrical engineer for the Navy then working in local power
plants. The patient's daughter [**Name (NI) **] [**Name (NI) **] will bring the
patient to the procedure and arrange transportation home.
.
Tobacco: smoked cigars 40-50 years ago
ETOH: rare
Family History:
Brother died of a "heart" problem at the age of 88. He thinks
his mother may also have died of heart problems but he is not
really sure.
Physical Exam:
PHYSICAL EXAMINATION on admission
VS: T= 98 BP=102/41 HR=64 RR=18 O2 sat= 99% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
PHYSICAL EXAM ON DISCHARGE
VS: T 97.5, HR 60s, BP 120s/60s, RR 20, O2 sat 98% on RA
GEN: NAD, A&OX3
HEENT: supple, JVP ~ 8cm
HEART: RRR, good S1, S2, no m/r/g
LUNG: CTA BL
ABD: soft, NT/ND, no HSM
EXT: no pitting edema, DP/PT 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
[**2156-12-14**] 07:30AM BLOOD WBC-7.4 RBC-3.50*# Hgb-11.3* Hct-32.3*
MCV-92 MCH-32.3*# MCHC-35.0 RDW-12.6 Plt Ct-159
[**2156-12-14**] 04:54PM BLOOD Neuts-75.8* Lymphs-17.2* Monos-5.7
Eos-0.9 Baso-0.4
[**2156-12-14**] 07:30AM BLOOD PT-11.9 PTT-25.1 INR(PT)-1.1
[**2156-12-14**] 07:30AM BLOOD Glucose-106* UreaN-35* Creat-1.5* Na-137
K-4.7 Cl-105 HCO3-23 AnGap-14
[**2156-12-14**] 04:54PM BLOOD ALT-36 AST-51* LD(LDH)-246 AlkPhos-48
TotBili-0.4
[**2156-12-14**] 04:54PM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.6 Mg-1.9
[**2156-12-14**] 12:54PM BLOOD Type-ART pO2-179* pCO2-32* pH-7.38
calTCO2-20* Base XS--4 Intubat-INTUBATED
[**2156-12-14**] 12:54PM BLOOD Glucose-134* Lactate-0.7 Na-136 K-4.1
Cl-112*
[**2156-12-14**] 12:54PM BLOOD Hgb-9.2* calcHCT-28
.
DISCHARGE LABS:
[**2156-12-16**] 06:55AM BLOOD WBC-7.1 RBC-3.32* Hgb-10.6* Hct-30.1*
MCV-91 MCH-31.9 MCHC-35.1* RDW-13.3 Plt Ct-107*
[**2156-12-16**] 06:55AM BLOOD PT-12.1 PTT-23.9* INR(PT)-1.1
[**2156-12-16**] 06:55AM BLOOD Glucose-98 UreaN-25* Creat-1.2 Na-134
K-4.8 Cl-105 HCO3-23 AnGap-11
[**2156-12-16**] 06:55AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
.
URINE:
[**2156-12-16**] 10:24AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2156-12-16**] 10:24AM URINE RBC-89* WBC-15* Bacteri-FEW Yeast-NONE
Epi-<1
.
MICROBIOLOGIC DATA:
[**2156-12-14**] MRSA screen - pending
[**2156-12-14**] Blood culture - pending
.
CYTOLOGY
[**12-16**] urine - pending
.
IMAGING STUDIES:
[**2156-12-14**] CXR - ReportLeft transvenous pacemaker leads end in the
standard position within the right Preliminary Reportatrium,
right ventricle and through the coronary sinus. There is no
pleural Preliminary Reporteffusion or pneumothorax. Bilateral
lungs are expanded and clear. Ill-defined
Preliminary Reportopacity with lucency in the right lower
paracardiac region is likely a Preliminary Reportherniated bowel
loop. Mildly enlarged heart size, mediastinal and hilar
Preliminary Reportcontours are normal. Aortic arch and
descending thoracic aorta are moderately calcified (Preliminary
Report).
.
[**2156-12-15**] CT ABD & PELVIS W & W/O
IMPRESSION
1. No evidence of retroperitoneal or intra-abdominal bleed.
2. Heterogeneous high-density material within the bladder which
is
nondependent and appears adherent to the bladder wall. Recommend
further
evaluation with contrast-enhanced CT/MRI or ultrasound.
3. Benign-appearing bony lesion in the right ilium is most
consistent with a bone island. Given no history of prostate
cancer, attention on followup
studies is indicated.
4. Large midline abdominal wall hernia containing loops of
unobstructed small bowel without evidence of incarceration or
strangulation.
5. Small left pleural effusion and trace right pleural effusion
with right
pleural thickening.
6. Cholelithiasis.
7. Large hiatal hernia.
.
[**2156-12-15**] 2D-ECHO - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is moderate regional left
ventricular systolic dysfunction with inferior and
infero-lateral akinesis (LVEF 35%). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. 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. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
This is an 86 year-old with a history of coronary artery disease
who is s/p CABG x 5 in [**2156**] who
presented with a history of ventricular tachycardia and
underwent ablation on [**2156-12-14**] with procedure complicated by
gross hematuria.
.
ACTIVE ISSUES
# GROSS HEMATURIA - The patient underwent his ventricular
tachycardia ablation on [**2156-12-14**] and was noted to have gross
hematuria with clot burden following Foley catheterization; with
evidence of a hemtocrit drop from 32.3% to 23.3%. He was
admitted to the Coronary care unit for closer monitoring and was
transfused 2 units of packed red blood cells. His hematocrit
improved to 27% following transfusion. Urologic surgery was
consulted and placed a three-way irrigating Foley catheter. He
had some residual clot burden, but this was otherwise stable.
Urine cytology was obtained and an outpatient cystoscopy will be
performed. He remained hemodynamically stable otherwise.
Terazosin and Finasteride were continued.
.
# VENTRICULAR TACHYCARDIA, STATUS-POST ABLATION - The patient
has a history of ventricular tachycardia. His EP study was
notable for a mixed cardiomyopathy with inferior scar and global
LV dysfunction. Multiple morphologies of VT were noted, induced
with programmed electrical stimulation; all eminating from the
scar. Two morphologies were successfully ablated after mapping -
along basal, septal and lateral scar margins. The patient had no
further episodes of ventricular tachycardia following the
ablation and remained hemodynamically stable. He received single
doses of Vancomycin and Ceftriaxone following his procedure for
prophylaxis. He was not continued on any anti-arrhythmics.
.
CHRONIC ISSUES
# CORONARY ARTERY DISEASE - The patient has a history of
significant coronary disease and markedly depressed ejection
fracture with nuclear imaging showing irreversible deficits from
prior ischemic events. He presented without chest pain or
concern for active ischemia for his outpatient VT ablation. We
continued his Aspirin, ACEI, Carvedilol, Simvastatin and Imdur,
his home medications.
.
# CONGESTIVE HEART FAILURE - The patient's home heart failure
regimen was continued and he had no evidence of volume overload
or signs of exacerbation of his underlying heart failure. We
aimed for his goal fluid balance to be even and continued his
ACEI, beta-blokcer, Lasix and Spironolactone. His daily weights,
in's and out's and fluid balances were closely monitored.
.
# HYPERTENSION - We continued his Carvedilol, Lisiniopril and
Imdur.
.
# HYPERLIPIDEMIA - We continued Simvastatin at his home dosing.
.
# PERIPHERAL NEUROPATHY - We continued Gabapentin at his home
dosing.
.
TRANSITION OF CARE ISSUES:
# CODE STATUS: Full
# PENDING STUDIES AT DISCHARGE:
- Blood culture [**12-14**] - NGTD
- MRSA screening - pending
- Urine cytology - [**12-15**]
# MEDICATION CHANGES
- START aspirin 81 mg qd
# FOLLOW UP PLAN
- PCP follow up on [**2156-12-24**]
- Urology follow up on [**2156-12-27**] for cystoscopy
- Continue with routine pacemaker followup
Medications on Admission:
CARVEDILOL 12.5 mg Tablet by mouth twice a day
ISOSORBIDE MONONITRATE 60 mg Tablet ER by mouth once a day
SIMVASTATIN 10 mg Tablet by mouth once a day
ASPIRIN 325 mg Tablet by mouth once a day
LISINOPRIL 10 mg Tablet by mouth once a day
FUROSEMIDE 20 mg Tablet by mouth every other day
MEGESTROL 625mg/5 mL Suspension - 1 (One) tsp by mouth every day
NITROGLYCERIN 0.4 mg Tablet SL every 5 minutes X 2 PRN chest
pain
OMEPRAZOLE 20 mg Capsule EC by mouth twice a day
POLYETHYLENE GLYCOL 3350 [MIRALAX] 17 gram PO once a day
Terazosin 1mg QHS
FINASTERIDE 5 mg Tablet by mouth once a day
GABAPENTIN 900 mg Capsule in the morning, 300mg Capsule at night
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Megace ES 625 mg/5 mL Suspension Sig: Five (5) mL PO once a
day.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5-minutes as needed for chest pain: Please do
not use more than 3 times total at one time.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
10. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QAM
(once a day (in the morning)).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QPM (once
a day (in the evening)).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
15. Outpatient Lab Work
Please obtain lab for CBC and sent the result to
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] at [**Hospital1 **] [**Hospital1 1474**] Tele: [**Telephone/Fax (1) 17919**], Fax:
[**Telephone/Fax (1) 87528**]
Discharge Disposition:
Home With Service
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Care
Discharge Diagnosis:
Primary Diagnoses:
1. Acute gross hematuria
2. Ventricular tachycardia ablation
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
3. Ischemic cardiomyopathy
4. Biventricular ICD placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 56636**],
.
You came to our hospital for a procedure for your recurrent
abnormal heart rhythm called ventricular tachycardia. You
underwent successful ablation in the cath lab. However, you
were found to have bleeding in your urine, and was admitted to
the Coronary Care Unit (CCU). Urology was consulted regarding
the management of your bloody urine and an irrigating Foley
catheter was placed. You were transfused 2 units of packed red
blood cells given a drop in your hematocrit. A CT study showed
normal kidneys with some concern for a bladder mass or residual
clot burden. You will follow-up with Urology as an outpatient
and a cystoscopy will be performed.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
- Please STOP taking aspirin 325 mg, instead, please START to
take aspirin 81 mg tablet by mouth once daily
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 17919**]
Appointment: FRIDAY [**12-25**] AT 11:15AM
Department: SURGICAL SPECIALTIES
When: MONDAY [**2156-12-27**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4271, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4775
} | Medical Text: Admission Date: [**2125-3-23**] Discharge Date: [**2125-4-6**]
Date of Birth: [**2046-10-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Fever and vomiting
Major Surgical or Invasive Procedure:
[**2125-3-27**]: Sternal wound exploration, Sternal debridement, with
placement of VAC dressing
[**2125-3-26**]: Left chest tube insertion
[**2125-3-26**]: Bronchoscopy
History of Present Illness:
Mrs. [**Known lastname 547**] underwent CABGx3/AVR on [**2-20**] with Dr. [**Last Name (STitle) **]. Her post
op course was significant for brief atrial fibrillation and was
treated with a course of levaquin for an upper respiratory
infection. She was discharged to rehab on
POD 7. She was readmitted [**3-2**] with left sided chest pain
w/inspiration radiating to her back. CXR at OSH showed mod to
large left effusion-per report. She was diuresed but not
responding well initially. Echocardiogram was performed and
showed the heart to be under filled. Albumin and blood were
given with good response in urine output and hemodynamics. An
ultrasound was done to assess left pleural effusion which
revealed minimal fluid. She was started on Keflex initially for
sternal wound erythema which resolved. However, Keflex was
continued for the saphenous vein site which was warm and
erythematous and she completed a 7 day course. She continued on
Coumadin with a therapeutic INR for post operative atrial
fibrillation. She was transferred to rehab [**2125-3-5**]. She is
readmitted today with fever, vomiting, + staph from blood and
sputum cultures as well as a right lower lobe PNA per OSH
report. Tx'd to [**Hospital1 18**] for further sepsis workup.
Past Medical History:
Past Medical History:
mild dementia, asthma, OA, hypothyroidism, mod AS,
polymyalgia, anemia, afib, Right renal cyst, GERD, vaginal
enterocele, PVD, open CCY ([**2105**])
Past Surgical History
open CCY ([**2105**])
s/p CABGx3/AVR([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue) [**2125-2-20**]
s/p Left superficial femoral artery to anterior tibial bypass
with in situ saphenous vein graft, [**2124-6-1**]
Social History:
Lives with: alone in nursing home ([**Location (un) **] village)
Occupation: retired
Tobacco: 30 yr x 1ppd, quit 30 years ago
ETOH: never
Race:caucasian
Last Dental Exam:>30 years ago
Family History:
Family History: Father died of MI at 46, one brother died of MI
at
45, another brother died of MI at 56
Physical Exam:
Afebrile Pulse: 73 Resp: 18 O2 sat: 07% on 2L
B/P Right: 113/71 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs decreased on L side[] Lower part of sternal
incision
has purulent drainage. Sternal click could not be elicited.
Heart: RRR [] Irregular [x] Murmur SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right/ Left: transmitted murmur
Pertinent Results:
Admission Labs:
[**2125-3-23**] PT-31.0* PTT-37.5* INR(PT)-3.1*
[**2125-3-23**] PLT COUNT-158#
[**2125-3-23**] NEUTS-84.9* LYMPHS-11.1* MONOS-3.4 EOS-0.4 BASOS-0.2
[**2125-3-23**] WBC-12.1* RBC-3.49* HGB-10.3* HCT-31.3*
[**2125-3-23**] CALCIUM-8.6 PHOSPHATE-4.7*# MAGNESIUM-2.2
[**2125-3-23**] GLUCOSE-96 UREA N-31* CREAT-1.5* SODIUM-143
POTASSIUM-3.2* CHLORIDE-110* TOTAL CO2-22
Discharge Labs:
[**2125-4-4**] WBC 8.3, HGB 13.1, HCT 41, PLT 367
[**2125-4-3**] WBC 9.6, HGB 11.5, HCT 36.4, PLT 485
[**2125-4-4**] GLUCOSE-92 UREA N-24* CREAT-1.3* SODIUM-139
POTASSIUM-3.4* CHLORIDE-98* HCO3-36
[**2125-4-2**] GLUCOSE-92 UREA N-24* CREAT-1.3* SODIUM-142
POTASSIUM-4.0* CHLORIDE-102* HCO3-35
[**2125-3-27**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Conclusions
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. There are simple atheroma in the ascending
aorta. There are simple atheroma in the descending thoracic
aorta. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The aortic
valve prosthesis leaflets appear to move normally. The
transaortic gradient is normal for this prosthesis. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
[**2125-3-27**] 2:30 pm TISSUE BONE-STERNAL.
**FINAL REPORT [**2125-3-31**]**
GRAM STAIN (Final [**2125-3-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2125-3-30**]):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 291-5206A [**2125-3-27**].
ANAEROBIC CULTURE (Final [**2125-3-31**]): NO ANAEROBES ISOLATED.
[**2125-3-27**] 2:30 pm TISSUE CHEST STERNAL CONTAMINATED.
**FINAL REPORT [**2125-3-31**]**
GRAM STAIN (Final [**2125-3-27**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI in
PAIRS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 82707**] ON [**2125-3-27**] @ 5:30PM.
TISSUE (Final [**2125-3-30**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML _________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2125-3-31**]): NO ANAEROBES ISOLATED.
[**2125-3-27**] Lower Extremity Ultrasound
[**Doctor Last Name **]-scale and color Doppler imaging of the common femoral,
superficial femoral, and popliteal veins were performed. Normal
compressibility, flow, waveforms, and augmentation is
demonstrated. No intraluminal thrombus is identified.
IMPRESSION: No lower extremity deep venous thrombosis
bilaterally.
[**2125-3-31**] CHEST PORT. LINE PLACEMENT
Comparison with [**2125-3-29**]. There is interval improvement in
pulmonary vascular congestion. Small pleural effusions are more
apparent. A right subclavian catheter remains in place. A PICC
line has been inserted on the right and terminates in the region
of the cavoatrial junction or right atrium. IMPRESSION: Line
placement as described. Small pleural effusions may have
increased slightly in size. Interval improvement in pulmonary
vascular congestion.
[**2125-4-2**] Upper Extremity Ultrasound
FINDINGS: Grayscale, color, and Doppler imaging was obtained on
the right jugular, subclavian, axillary, brachial, cephalic, and
basilic veins. There is normal flow, compression and
augmentation seen in all the vessels. IMPRESSION: No evidence of
deep vein thrombosis in the right arm.
Brief Hospital Course:
Ms [**Known lastname 547**] is s/p CABGx3/AVR on [**2-20**] with Dr. [**Last Name (STitle) **]. She was
discharged to rehab on
POD 7. Her post-op course was complicated by Atrial fibrillation
and upper respiratory tract infection treated with
Ciprofloxacin. She was readmited from rehab on [**2125-3-22**] to OSH
with fever, nausea and vomiting. Blood and sputum cultures were
positive for coag+ staph. Additionally she had a left upper lobe
PNA per OSH report. Started on Vancomycin and Zosyn, and was
found to have purulent discharge from lower part of sternum. CXR
showed LUL pneumonia and CT chest showed opacification of the L
hemithorax w/o aerated lung. An ultrasound revealed fluid so a
thoracentesis was performed and drained about 700 cc's. The
chest Xray was only minimally improved so the patient was
intubated and a bronchoscopy was performed. A BAL revealed no
micro-organisms. The following morning she was brought to the
operating room, where a sternal wound exploration, sternal
debridement, and V.A.C. dressing was placed. Please see
operative report for additional details. She tolerated the
operation well and post-operatively was returned to the cardiac
surgery ICU. Over the next 24 hours she was weaned from the
ventilator and extubated. She remained in the ICU for pulmonary
hygiene. The OR specimens eventually grew out Methicillin
Resistant Staph Aureus. She was initially treated with
Vancomycin and Gentamycin. Post-operatively the Gentamycin was
stopped, and Vancomycin was dosed for a goal level between 15 to
20. Over the next several days the patient remained
hemodynamically stable and her respiratory status gradually
improved. Nutrition was also suboptimal however she was cleared
after a swallow evaluation for a modified diet. A PICC line was
placed for long term antibiotic administration. The ID service
was consulted and will monitor her Vancomycin as an outpatient.
She will also require follow up with the cardiac and plastic
surgeons as an outpatient who will monitor her VAC dressing. She
continued to make clinical improvements and was cleared for
discharge to rehab on postoperaive day eight.
Medications on Admission:
Medications on transfer:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS bedtime).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10.Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11.Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
12.Primidone 50 mg Tablet Sig: One (1) Tablet PO HS
13.Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14.Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours)PRN
15.Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16.Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2)Puff Inhalation Q6H (every 6 hours) PRN
17.Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) PRN
18.Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
19. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: Goal INR [**3-14**] for Atrial Filbrillation.
20. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 2 months.
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID
22. Folic Acid 1 mg Tablet Sig: One (1) Tabl
23. Vancomycin IV
24. Zosyn IV
Discharge Medications:
1. Outpatient Lab Work
Labs: Weekly labs - CBC with diff, electrolytes, BUN/Cr,
Vancomycin trough, with reults to [**Hospital **] clinic - fax [**Telephone/Fax (1) 1419**]
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
16. Vancomycin 500 mg Recon Soln Sig: 750mg Recon Solns
Intravenous Q48H (every 48 hours): titrate for goal between
15-20.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation every six (6) hours.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation every six (6) hours.
19. Furosemide 10 mg/mL Syringe Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day): 20mg IV twice daily.
20. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
23. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: 20
meq twice daily - may need to titrate accordingly.
24. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous AC/HS: 0-70 hypoglycemia protocol/71-119 0
units/120-140 2 units/141-199 4 units/200-239 6 units/240-280 8
units/greater than 280, notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
- MRSA, Sternal Wound Infection with Dehiscence s/p Sternal
wound exploration, Sternal debridement, and V.A.C. dressing
placement.
- s/p Coronary Artery Bypass/Aortic Valve Replacement [**2125-2-9**]
- Anemia
- Atrial fibrillation
- Peripheral Vascular Disease
- Aspiration Precautions
Discharge Condition:
Mental Status:Alert and oriented x3, follows commands
Level of Consciousness:Arousable and interactive, somewhat
somnolent
Activity Status:Out of Bed with assistance to chair or
wheelchair
Sternal Wound with VAC dressing
Pain control with Ultram
Discharge Instructions:
Please shower daily including washing around incisions gently
with mild soap, no baths or swimming.
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 until cleared by cardiac surgeon
No lifting more than 10 pounds
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision,
Followup Instructions:
1)Cardiac Surgeon - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:
[**2125-4-11**] 1:15 PM
2)Infectious Disease - [**First Name5 (NamePattern1) 402**] [**Last Name (NamePattern1) 2688**] ID WEST (SB)
Phone:[**Telephone/Fax (1) 457**] Date/Time: [**2125-4-17**] 9:30 AM
3)Plastic Surgeon - Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 1416**] Tuesday
[**4-17**] at 1045 am - [**Apartment Address(1) 1414**] [**Location (un) **], [**Numeric Identifier 82708**]
4)Labs: Weekly labs - CBC with diff, electrolytes, BUN/Cr,
Vancomycin trough, please fax results to [**Hospital **] clinic - fax #
[**Telephone/Fax (1) 1419**]
5)PCP: [**Name10 (NameIs) 1447**],[**Name11 (NameIs) 1569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 44915**] 2-3 weeks after discharge
from rehab
6)Cardiologist: Dr [**Last Name (STitle) 82705**], [**First Name3 (LF) 82704**] 2-3 weeks after discharge from
rehab
Completed by:[**2125-4-4**]
ICD9 Codes: 486, 5180, 7907, 2762, 5119, 4439, 2449, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4776
} | Medical Text: Admission Date: [**2144-7-19**] Discharge Date: [**2144-7-21**]
Date of Birth: [**2071-4-13**] Sex: M
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
Right Craniotomy for evacuation of large IPH
History of Present Illness:
HPI: Patient is a 73M with PMH significant for HTN, CAD and
polycythemia who was in his usual state of health this afternoon
when he stumbled over onto the floor. He was taken to OSH where
their work-up revealed a sizable IPH. He was reportedly AOX3 at
the OSH, but upon arrival to [**Hospital1 18**] ED was AOx2.
Past Medical History:
1. CAD
2. HTN
3. Polycythemia; multiple transfusion history secondary to his
condition per family reports.
Social History:
Social Hx: Married, resides at home with wife.
Family History:
Family Hx: non-contributory
Physical Exam:
O: T:afebrile BP: HR: RR: O2Sats:
intubated, mechanically ventillated
Gen: WD/WN elderly male, sedated on Propofol
HEENT: normocephalic, oozing lt frontal laceration.
Pupils: asymmetric Lt 3.5mm, Rt 6.5mm. Non reactive.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: No response to voice, no commands. Delayed
localization with LEFT upper extremity to noxious stimulus, weak
withdrawal
LLE. Posturing on right side with noxious stimulus. +cough with
deep ET
suctioning.
Cranial Nerves:
I: Not tested
II: Right pupil 6.5mm, Left pupil 3.5mm
III, IV, VI-XII: unable to assess
Toes upgoing bilaterally
Pertinent Results:
[**2144-7-19**] 10:18PM GLUCOSE-229* UREA N-33* CREAT-1.7*
SODIUM-131* POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-18* ANION
GAP-21*
[**2144-7-19**] 10:18PM ALT(SGPT)-17 AST(SGOT)-33 LD(LDH)-722*
CK(CPK)-64
[**2144-7-19**] 10:18PM CK-MB-NotDone cTropnT-0.12*
[**2144-7-19**] 10:18PM CALCIUM-7.9* PHOSPHATE-7.3*# MAGNESIUM-1.8
[**2144-7-19**] 10:18PM HAPTOGLOB-81
[**2144-7-19**] 10:18PM WBC-55.4* RBC-2.84* HGB-8.9* HCT-24.7* MCV-87
MCH-31.4 MCHC-36.0* RDW-18.6*
[**2144-7-19**] 10:18PM PLT COUNT-83*
[**2144-7-19**] 10:18PM PT-17.2* PTT-36.4* INR(PT)-1.6*
[**2144-7-19**] 10:18PM FIBRINOGE-669* D-DIMER-3512* THROMBN-19.2
[**2144-7-19**] 10:18PM PARST SMR-NEGATIVE
[**2144-7-19**] 08:25PM TYPE-ART RATES-/11 TIDAL VOL-700 O2-66 PO2-90
PCO2-41 PH-7.34* TOTAL CO2-23 BASE XS--3 INTUBATED-INTUBATED
Brief Hospital Course:
Dr. [**First Name (STitle) **] met with family and discussed surgical options for
evacuation of the IPH, prognosis with/without surgery was felt
to be poor. Family wishing to proceed with surgical intervention
in best efforts. Preoperatively pt had CTA imaging to evaluate
for an aneurysmal source for the bleed. Showed Post operative CT
scan showed Iiterval worsening of right frontal parenchymal
hemorrhage and mass effect
with now 17 mm left [**Hospital1 **] subfalcine herniation, compared to
prior comparative
measurement of 14 mm. There is also interval effacement of
basilar and
perimesencephalic cistern, raising concern for impending uncal
herniation. The
preliminary review of the CTA portion of the study, demonstrates
a 4 mm focal
ectatic segment just proximal to the basilar bifurcation into
PCA (3:252), The
right PCA is relatively [**Name2 (NI) 79305**] and a ruptures circle of
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 53283**] or
AVM as a precipitant of fall could not be excluded.
Following surgical evacuation CT imaging was completed on
[**2144-7-20**] which revealed new bleed extending beneath the surgical
bed with worse vasogenic edema. Mannitol therapy continues in an
effort to contain this edema. Physical exam remains consistent
with fixed pupils. Left 3mm, Right 6mm. Corneals + but slowed in
the left cornea. Mechanically ventilated with some spontaneous
respirations. He does not follow commands when pt allowed to
lighten from sedation. Pt localizing in Lt upper extremity to
noxious stimuli, Left LE with withdrawl to stimulus and only
extensor posturing on the right side. Family aware of the
gravity of pts illness and are supportive. Family meeting held
and maintain that Mr. [**Known lastname **] would not like to be maintained
on full time nursing care or would not wish for tracheostomy and
PEG tube placement for nutritional support. It was felt that
comfort measures would be the most appropriate course of care
given his wishes and present condition.He was extubated [**2144-7-20**]
and started on morphine drip. With family present, he expired
14:12 on [**2144-7-21**].
Medications on Admission:
1. Hydrea 1500mg daily
2. Verapamil 180mg daily
3. Elavil 50mg daily
4. Trilafon 4mg daily
5. Niaspan 1gm daily
6. Colchicine 0.6mg daily
7. Toprol XL 100mg daily
8. MVI
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
intraparenchymal hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Completed by:[**2144-7-21**]
ICD9 Codes: 431, 5849, 2859, 412, 2720, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4777
} | Medical Text: Admission Date: [**2160-4-22**] Discharge Date: [**2160-4-30**]
Date of Birth: [**2083-12-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Right great toe ulcer.
Major Surgical or Invasive Procedure:
Right below-knee popliteal-to-dorsalis pedis artery bypass with
non-reversed saphenous vein graft. Angioscopy.
History of Present Illness:
Pt is a 76F admitted s/p Right [**Doctor Last Name **]-DP BPG [**4-22**] w/ chronic Left
heel ulcer and Right hallux gangrene. Pt is followed by Dr.
[**Last Name (STitle) **] and was last seen in clinic [**4-1**] at which point the left
heel ulcer was debrided and pt instructed to continue daily
dressing changes. No evidence of infection was noted at that
time. She denies any recent h/o fevers, chills, nausea,
vomitting. She is c/o significant pain to BL LE.
ROS: Pt denies, CP, SOB, URI symptoms. Remaining ROS per HPI
above
Past Medical History:
- DM2 - insulin dependent x30y, c/b neuropathy.
- PVD
- GERD
- paroxysmal atrial fibrillation
- h/o gastritis
- h/o pancreatitis\
- h/o stress incontinence, urinary retention
- h/o CVA (left occipital infarct)
- s/p cervical fusion, lumbar disc surgery
- glaucoma
- R eye blindness
.
Social History:
Pt lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] presently, denies tobbacco, alcohol,
IVDU. Previously lived with daughter, [**Name (NI) **]. Was walking with
walker and performing her ADLs fairly independently prior to
recent hospitalization.
Family History:
noncontributary
Physical Exam:
PHYSICAL EXAM .
Tmax:99.0 Tc:99.0 Rate:74 BP:133/58 RR:20 P02:94% on RA
Gen: NAD
HEENT: PERRLA, EOMi, No carotid brui
CV: RRR
Chest: CTA
Abd: sof, NT, ND, act BS
Ext: [**1-4**]+ pedal edema bilaterally, right and left great toes
with dry gangrene. Foul smelling. Small ulcers relatively c/d/i
around lateral toes.
Pulses: Fem DP PT
p d d
p d d
VASCULAR
Pedal Pulses: [] Palpable [x] Non-palpable. monophasic sig
on L
Sub-Papillary VFT: [x] < 3 sec. [] > 3 sec. [] Immediate
Extremities: [x] pitting edema [] non-pitting edema
[] Anasarca
NEUROLOGICAL Sensation: [x] Intact [] Absent
Proprioception: [x] Intact [] Absent
INTEGUMENT:
Ulceration(s): [x] Full thickness [] Partial thickness
[] Pre/Post-ulcerative [] Absent
Location: [x] L Heel [] Midfoot [x] R hallux
Drainage: [x] Serous [] Sanguineous [] Purulent
Base: [] Granular [x] Fibrous [] Eschar
[] Tendon/Capsule/Bone
Margins: [] Regular [x] Irregular [] Hyperkeratotic
[] Macerated [] Thin/Atrophic
Qualities: [x] Undermines [x] Tracks [] Probes to bone
DRESSING AND SPLINTS
Multipodus Boots: [] Intact [x] Absent
Dressing(s): [] Clean Intact [] Dry [x] Serous
[x] Sanguineous [] Purulent
Pertinent Results:
[**2160-4-25**] 10:18AM BLOOD WBC-11.9* RBC-3.63* Hgb-9.6*# Hct-30.2*#
MCV-83 MCH-26.5* MCHC-31.9 RDW-15.3 Plt Ct-270
[**2160-4-25**] 10:18AM BLOOD Glucose-213* UreaN-12 Creat-0.7 Na-137
K-4.6 Cl-100 HCO3-28 AnGap-14
[**2160-4-25**] 10:18AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9
Brief Hospital Course:
[**2160-4-22**] Mrs. [**Known lastname **],[**Known firstname **] was admitted on [**4-22**] with a Right
great toe ulcer.
She agreed to have an elective surgery. Pre-operatively, she was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a
PROCEDURE:
1. Right below-knee popliteal-to-dorsalis pedis artery
bypass with non-reversed saphenous vein graft.
2. Angioscopy.
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged to a rehabilitation
facility in stable condition.
To note Podiatry was consulted. Pt on Bactrim for her toe ulcer.
Medications on Admission:
Clopidogrel 75 mg' Gabapentin 500 mg' Gabapentin 600 QHS4.
Metoprolol Succinate 50 mg SR'Simvastatin 20' Pantoprazole
40'Tolterodine 1 mg' Aspirin 81 mg' Calcium Carbonate 500 mg''
Docusate Sodium 100''
Ferrous Gluconate 325' Senna 8.6'' prn 1 Cyanocobalamin 500''
Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] Brimonidine 0.15 % Drops Sig: One Q8H
Lisinopril 10' Humalog Mix 75-25 100 unit/mL (75-25) Suspension
Sig: 30
units Q AM, 20 units QHS Subcutaneous Q AM, and Q PM.
Acetaminophen 325 mg Q6 prn
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
9. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed for agitation, delusion.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for mild pain.
15. Insulin
Fingerstick QACHS
SC Fixed Dose Orders
Breakfast Bedtime
Humalog 75/25 15 Units Humalog 75/2510 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**1-4**] amp D50 [**1-4**] amp D50 [**1-4**] amp D50 [**1-4**] amp D50
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
> 350 mg/dL Notify M.D.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
PVD w/ non-healing right great toe ulcer
History of:
carotid stenosis
dementia
diabetes
urinary retention
GERD
Discharge Condition:
stable
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-5**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2160-5-7**] 9:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2160-5-15**] 3:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2160-5-20**] 2:15
Completed by:[**2160-4-28**]
ICD9 Codes: 5990, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4778
} | Medical Text: Admission Date: [**2152-11-12**] Discharge Date: [**2152-11-15**]
Date of Birth: [**2066-4-17**] Sex: F
Service: MEDICINE
Allergies:
Diamox / fentanyl
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86F s/p trach after recent [**2152**] admit for gallstone pancreatitis
c/b ARDS and tracheostomy, sent in from rehab facility
w/increased work of breath (off vent x 8d) and hypoxic to 80s on
RA. She is anticoagulated w/fondaparinux since discharge to
rehab last month. No reported fevers but EMS reports increased
suctioning by rehab on the day of presentation.
.
in the ED, inital vitals were T 104 rectally, HR 108, BP 112/56,
Sat88%RA, with diffuse rhonchi in both lung fields, edema to the
knees. She was placed back on the vent and sat came up to 100s,
intitally they said that her ABG at outside facility was
7.29/92/51/44 O2sat 79% Fio2 35% through TM and NC. Her temp
here at the ED was 104 rectally.
.
An EKG showed sinus tach 103 NA/NI no STEMI. A CXR showed large
right pleural effusion (known). Blood cultures were drawn, and
patient was started on vanc 1g /zosyn 4.5 g/levofloxacin 750,
and given tylenol for T 104. Labs notable for a lactate of 3.4.
ABG shwoed 7.45/59/109, consistent with a metabolic alkalosis
with a potential compensatory respiratory acidosis, AG not
elevated at 8.
.
Last pressure prior to [**Hospital Unit Name 153**] transfer was 134/100 HR 94 RR 15
91-93% on AC control fiO2 80% TV 450 RR 15 PEEP 8. Midline
horizontal surgical incision from cholecystectomy, open in two
palces, but looks like a shallow ulceration taking time to heal,
so packed with gauze. no surrouding erythema.
.
On the floor, she's intubated.
.
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:
Past Medical History:
HTN
CHF
Afib
DVT
MR
Obstructive sleep apnea
COPD
stroke
MI
s/p lung tumor excision
Urinary incontinence
Right lower lobe infiltarte
right pleural effusion
hypoalbuminemia
gallstone pancreatitis c/b ARDS - 5 /[**2152**]
Respiratory distress and tracheostomy [**8-/2152**]
VRE UTI [**9-/2152**]
cholecystectomy and panreatic cystostomyx2 [**2152-10-20**]
C diff [**2152-10-27**] IV flagyl -> negative [**11-10**]
.
Past surgical:
Tracheostomy [**2-/2152**]
open cholecystectomy and cyst gastrostomy x2 [**10/2152**]
Social History:
lives in a rehab, in supervised housing. No tobacco, ethanol or
IVDA. ambulatory at baseline.
Family History:
NC
Physical Exam:
Admission Physical Exam
99.2 88/40 RR 20 99% on 90% endotrachial tube, CMV 16/450
Exam: diffuse rhonchi throughout both lung fields, 1+ edema to
knees, horiz [**Doctor First Name **] incision w/staples and 2 sm open areas
w/packing and fibrinous exudate, no surrounding erythema
General: moving fingers and toes, on mechanical ventilator
through the tracheostomy tube. Open eyes and trying to
communicate despite language barrier.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchi bilaterally (better after suctioning)
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
best heard at left lower sternal border (hard to assess given
her diffuse rhonchi) no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Upper
abdomen horizontal surgical scar with staples and 2 small open
areas with packing and fibrinous exudate, no surrounding
erythema
GU: foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis.
edematous lower extremities up to knees
Discharge Physical Exam
98.4 BP 138/67 RR 17 98% on Trach Mask 50%
Exam: diffuse rhonchi throughout both lung fields, 1+ edema to
knees, horiz [**Doctor First Name **] incision w/staples and 2 sm open areas
w/packing and fibrinous exudate, no surrounding erythema
General: moving fingers and toes, on tach mask
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchi bilaterally (better after suctioning)
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
best heard at left lower sternal border (hard to assess given
her diffuse rhonchi) no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Upper
abdomen horizontal surgical scar with staples and 2 small open
areas with packing and fibrinous exudate, no surrounding
erythema
GU: foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis.
edematous lower extremities up to knees
Pertinent Results:
CBC
[**2152-11-15**] 03:00AM BLOOD WBC-6.9 RBC-3.33* Hgb-9.7* Hct-29.8*
MCV-89 MCH-29.1 MCHC-32.6 RDW-16.8* Plt Ct-368
[**2152-11-14**] 03:09AM BLOOD WBC-6.8 RBC-3.60* Hgb-10.5* Hct-31.3*
MCV-87 MCH-29.2 MCHC-33.6 RDW-16.8* Plt Ct-370
[**2152-11-13**] 04:32AM BLOOD WBC-6.6 RBC-3.42* Hgb-9.8* Hct-30.0*
MCV-88 MCH-28.7 MCHC-32.7 RDW-16.9* Plt Ct-381
[**2152-11-12**] 06:27AM BLOOD WBC-9.1 RBC-3.42* Hgb-9.3* Hct-30.5*
MCV-89 MCH-27.3 MCHC-30.5* RDW-16.9* Plt Ct-377
[**2152-11-12**] 02:44AM BLOOD WBC-9.1 RBC-3.76* Hgb-10.6* Hct-31.7*
MCV-84 MCH-28.3 MCHC-33.5 RDW-16.9* Plt Ct-394
Diff:
[**2152-11-14**] 03:09AM BLOOD Neuts-68.6 Lymphs-20.3 Monos-7.7 Eos-3.0
Baso-0.4
[**2152-11-13**] 04:32AM BLOOD Neuts-68.6 Lymphs-22.4 Monos-7.7 Eos-1.0
Baso-0.3
[**2152-11-12**] 06:27AM BLOOD Neuts-73.5* Lymphs-17.7* Monos-8.2
Eos-0.3 Baso-0.2
[**2152-11-12**] 02:44AM BLOOD Neuts-80.6* Lymphs-13.1* Monos-5.5
Eos-0.5 Baso-0.2
Coag:
[**2152-11-13**] 04:32AM BLOOD PT-14.5* PTT-36.6* INR(PT)-1.3*
[**2152-11-12**] 06:27AM BLOOD PT-14.2* PTT-38.2* INR(PT)-1.2*
[**2152-11-12**] 02:44AM BLOOD PT-12.6 PTT-40.6* INR(PT)-1.1
Electrolytes:
[**2152-11-15**] 03:00AM BLOOD Glucose-89 UreaN-7 Creat-0.3* Na-137
K-3.7 Cl-96 HCO3-38* AnGap-7*
[**2152-11-14**] 03:09AM BLOOD Glucose-93 UreaN-7 Creat-0.4 Na-135 K-3.7
Cl-96 HCO3-34* AnGap-9
[**2152-11-13**] 04:32AM BLOOD Glucose-102* UreaN-11 Creat-0.4 Na-138
K-4.0 Cl-95* HCO3-37* AnGap-10
[**2152-11-12**] 06:27AM BLOOD Glucose-117* UreaN-21* Creat-0.6 Na-135
K-5.3* Cl-92* HCO3-37* AnGap-11
[**2152-11-12**] 02:44AM BLOOD Glucose-159* UreaN-19 Creat-0.5 Na-134
K-6.0* Cl-88* HCO3-38* AnGap-14
LFTs:
[**2152-11-12**] 02:44AM BLOOD ALT-8 AST-25 LD(LDH)-248 AlkPhos-125*
TotBili-0.2
Elements:
[**2152-11-15**] 03:00AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.1
[**2152-11-14**] 03:09AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.6
[**2152-11-13**] 04:32AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.5*
[**2152-11-12**] 06:27AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.5*
Digoxin:
[**2152-11-12**] 02:44AM BLOOD Digoxin-1.0
Blood gas:
[**2152-11-13**] 02:53PM BLOOD Type-ART Temp-36.8 PEEP-5 FiO2-50
pO2-110* pCO2-48* pH-7.52* calTCO2-41* Base XS-14
Intubat-INTUBATED Vent-SPONTANEOU
[**2152-11-12**] 01:25PM BLOOD Type-MIX Temp-37.6
[**2152-11-12**] 07:32AM BLOOD Type-MIX Comment-GREEN TOP
[**2152-11-12**] 03:41AM BLOOD Type-ART Rates-/15 Tidal V-450 FiO2-80
pO2-109* pCO2-59* pH-7.45 calTCO2-42* Base XS-14 AADO2-400 REQ
O2-70 -ASSIST/CON Intubat-INTUBATED
Lactate:
[**2152-11-12**] 01:25PM BLOOD Lactate-1.6
[**2152-11-12**] 07:32AM BLOOD Lactate-3.8*
[**2152-11-12**] 03:41AM BLOOD Lactate-3.8* K-5.3*
[**2152-11-12**] 03:01AM BLOOD Lactate-3.4*
Urine:
[**2152-11-12**] 06:28AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2152-11-12**] 02:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2152-11-12**] 06:28AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2152-11-12**] 02:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2152-11-12**] 06:28AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2152-11-12**] 02:45AM URINE RBC-1 WBC-10* Bacteri-FEW Yeast-NONE
Epi-<1
Microbiology:
[**2152-11-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT Negative
[**2152-11-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Negative
[**2152-11-12**] URINE URINE CULTURE-FINAL INPATIENT No
growth
[**2152-11-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL
INPATIENT Negative
[**2152-11-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2152-11-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Imaging:
- CHEST (PORTABLE AP) Study Date of [**2152-11-12**] 2:31 AM
IMPRESSION:
1. Moderate right pleural effusion with associated right basilar
compressive atelectasis. Cannot exclude an infectious process at
the right lung base.
2. Small left pleural effusion.
3. Mild interstitial pulmonary edema, predominantly on the
right.
- CHEST (PORTABLE AP) Study Date of [**2152-11-12**] 6:40 AM
REASON FOR EXAMINATION: New onset of respiratory failure after
recent
cholecystectomy.
Portable AP radiograph of the chest was reviewed in comparison
to [**2152-11-12**].
Tracheostomy tube is in place with the tip being 6 cm above the
carina.The
NG tube tip passes below the diaphragm, tip not included in the
field of
view.Right PICC line tip is at the level of superior SVC.
There are interval progression of bilateral consolidations,
right more than left, associated with pleural effusion and right
lower lung atelectasis.
- BILAT LOWER EXT VEINS Study Date of [**2152-11-14**] 2:15 PM
IMPRESSION:
Normal appearance of the deep venous structures in both right
and left lower extremity. No evidence of deep venous thrombosis.
Brief Hospital Course:
86F s/p trach after recent [**2152**] admit for gallstone pancreatitis
c/b ARDS, anticoagulated w/fondaparinux since discharge to rehab
last month, sent in from rehab facility w/increased work of
breath (off vent x 8d), increased secretions requiring
suctioning and hypoxic to 80s on RA, admitted to the ICU for
hypoxia.
# Hypotension: Unclear etiology, although elevated lactate and
lack of response to the 4 L in the ED did strongly suggest
septic shock. She was managed with early goal directed therapy,
and was started on a NorEpi gtt, which was able to be weaned off
by HD [**3-16**].
# Hypoxic hypercarbic respiratory failure: In the setting of
fever, increased oxygen demand, right pleural effusion and right
lower lobe infiltrate (per OSH report) and high lactate, could
consider sepsis, likely from the lung as a source. Mucus plug is
very possible as well given the increased secretions at the
rehab and improved lung exam after suctioning. Aspiration can
also be possible given her dysphagia per OSH records. Given she
has COPD, underlying COPD exacerbation might be contributing as
well. Patient was taken off abx on HD2, and remained afebrile
afterwards; initially required PS ventilation, but ultimately
was able to wean back to trach collar, despite removal of broad
spectrum antibiotics, as well as without active intetion for
diuresis, leading to the belief that this was secodnary to a
mucus plug or possible a viral etiology. Pulmonary embolism was
consider, but was felt lesss likely given her appropriate
anticogaluation with fondraprinaux, and her rapid recovery to
her baseline pulmonary function.
.
# Metabolic alkalosis: Felt to be most likely [**3-15**] hypercarbia
given her underlying COPD in addition to possible mucus plug
obstruction. Concerning for diuretic use leading to volume
contraction. Her bicarbonate has been consistently high in our
hospital in the 38-40 range, with the thought that she may have
some chronic respiratory acidosis secondary to her COPD.
.
# Abnormal UA: Her UA was slightly positive for UTI (WBC 10,
Bact few, sm Leuk) but nitrite negative. Might be contamination
given her urinary incontinence. Culture was negative. She was
not treated with any antibiotics for an extended period of time,
and did not endorse any symptoms during her stay.
# Hyperkalemia: Resolved. Last K 3.7 down from 6 on admission.
EKG was not concerning of hyperkalemic changes.
# Horizontal surgical incision: At both ends seems small open
areas with packing and fibrinous exudate, no surrounding
erythema. Wound care saw her and recommended the following:
.
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface: Atmos Air
Turn and reposition every 1-2 hours and prn
Heels off bed surface at all times
Waffle Boots to B/L LE's If OOB, limit sit time to one hour
at a time and sit on a pressure relief cushion.
Elevate LE's while sitting.
Moisturize B/L LE's and feet [**Hospital1 **].
ABD Incision:
Suggest Remove staples (OR [**2152-10-20**])( ICU team may need to
contact
surgeon at [**Hospital3 **] to coordinate their plan for her
incision)
-Commercial wound cleanser or normal saline to irrigate/cleanse
all open wounds.
Pat the tissue dry with dry gauze.
Apply DuoDerm Gel into the open wound sites along the incision
Pack loosely with [**Doctor Last Name 12536**] AMD (antimicrobial)1" packing strip
moistened with normal saline -hospital # [**Numeric Identifier 90877**]
Cover with dry gauze, ABD
Secure with Micropore tape.
Change dressing daily.
Support nutrition and hydration.
.
# Anemia: Unknown baseline. Normocytic anemia. Could be anemia
of chronic disease. Stable at 10.5/31.3 Tbil and LDH are not
suggestive of hemolytic process. Guiaic was negative.
.
#LE pain: Continued gabapentin, tylenol, and morphien for pain.
# Afib: well rate controlled 80's-90's while in the [**Hospital Unit Name 153**] without
restarting her home meds for rate control (metoprolol, dig and
dilt). We sent her home soly on her digoxin, with a plan for her
primary care to restart these medications as necessary.
#FEN: Consulted nutrition for tube feeds
# Communication: Patient, [**Name (NI) 90878**] [**Last Name (un) **] (Daughter)
[**Telephone/Fax (1) 90879**], [**Telephone/Fax (1) 90880**]
# Code: Full, goal is more comfort, family discussing DNR per
rehab notes
Medications on Admission:
vitamin C 500 mg PO twice daily
bumex 3 mg PO daily
digoxin 0.125 MG PO daily
diltiazem 90 mg four times a day
fondaparinux 2.5 mg SQ daily
gabapentin 100 mg cap 200 mg once daily 10 pm
gabapenting 100 mg VT twice daily 6am , 2pm
inslulin regular human scale
metochlopramide 2.5 mg PO/VT three times daily - standard
miconazole nitrate topical every 12 hour
pantoprazole SOD sesquihydrate 40 mg once daily
tiotropium bromide 18 mcg handihaler once a day
zinc sulfate 220 mg PO everyday
metoprolol tartrate 25 mg every 12 hours
----
PRN
acetamenophen 650 q 4 hr PRN fever
lorazepam 0.5 mg q 6 hr PRN
ondansetron 4 mg every 6 hr PRN
quetiapine 12.5 twice daily
oxycodone 5 mg q 4 hr PRN pain
Discharge Medications:
vitamin C 500 mg PO twice daily
bumex 3 mg PO daily
digoxin 0.125 MG PO daily
fondaparinux 2.5 mg SQ daily
gabapentin 100 mg cap 200 mg once daily 10 pm
gabapenting 100 mg VT twice daily 6am , 2pm
inslulin regular human scale
metochlopramide 2.5 mg PO/VT three times daily - standard
miconazole nitrate topical every 12 hour
pantoprazole SOD sesquihydrate 40 mg once daily
tiotropium bromide 18 mcg handihaler once a day
zinc sulfate 220 mg PO everyday
----
PRN
acetamenophen 650 q 4 hr PRN fever
lorazepam 0.5 mg q 6 hr PRN
ondansetron 4 mg every 6 hr PRN
quetiapine 12.5 twice daily
oxycodone 5 mg q 4 hr PRN pain
MEDS HELD ON TRANSFER:
metoprolol tartrate 25 mg every 12 hours (hold)
diltiazem 90 mg four times a day (hold)
both held for HR on discharge in the 60s, can be restarted per
rehab physician as needed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypercarbic respiratory failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname 15655**], it was a pleasure taking care of you in the
hospital. You were admitted from your facility because you were
having an increased work of breathing, hypoxia and fevers. When
you came to our hospital, you had a very low blood pressure, and
were noted to have a fever in the emergency department. We gave
you a great deal of fluid, and supported your blood pressure
with medications that help to raise the blood pressure. We also
helped your braething, which was difficulty for you, by hooking
you up to our ventilator. You were able to come off both the
ventilator as well as our medications that raise blood pressure,
and did not require any antibiotics. We suspect that you may
have had a small "mucus plug" or may have had a viral illness
which caused you to come to our hosptial.
When you leave the hospital:
- STOP Metoprolol 25 mg [**Hospital1 **] (have your doctor reassess your
heart rate in 24-48 hours to see if you need these medications
for better control)
- STOP Diltiazem 90 mg QID (have your doctor reassess your heart
rate in 24-48 hours to see if you need these medications for
better control)
We did not make any other cahnges to your medications, so pelase
continue to take them as you normally have been.
Followup Instructions:
Please have your rehabilitation facility make an appointment for
you in a week's time with your primary care physician.
ICD9 Codes: 0389, 5119, 4019, 496, 4240, 412, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4779
} | Medical Text: Admission Date: [**2201-5-2**] Discharge Date: [**2201-5-22**]
Date of Birth: [**2128-4-1**] Sex: M
Service: [**Last Name (un) **]
PROCEDURES DURING ADMISSION: None.
ADMISSION DIAGNOSES: History of EtOH abuse.
Parotid tumor.
DISCHARGE DIAGNOSES: Intracranial hemorrhage status post
fall.
Alcohol withdrawal.
Respiratory arrest on the floor requiring intubation.
Urinary tract infection.
Aspiration pneumonia.
Post head injury confusion.
Failure to pass swallow evaluation requiring total parenteral
nutrition.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with past medical history significant for EtOH abuse and
parotid tumor status post surgery, who was transferred to
[**Hospital1 69**] after a fall. The
patient had been drinking wine and had an unwitnessed fall.
The patient was found at the base of 14 stairs on a tile
floor with unknown loss of consciousness. Patient complained
of right elbow pain.
PAST MEDICAL HISTORY: Parotid tumor.
PAST SURGICAL HISTORY: Parotid surgery.
MEDICATIONS ON ADMISSION:
1. Amitriptyline.
2. Serax.
3. Librium.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile,
heart rate in the 100s, blood pressure is in the 120s/90s.
He was saturating 100 percent on room air. GCS of 14. His
head was atraumatic. He had no facial deformities. His neck
had a C collar in place. There was no tracheal shift. There
were no step-offs. His heart was regular. His lungs were
clear. His abdomen was soft, nontender, nondistended. His
rectal has normal tone, is guaiac negative. His extremities
had no deformities. He was tender over his right elbow. He
had a right hand abrasion. His back was nontender, no step-
offs and no deformities. Motor [**4-29**] grossly intact in all
four extremities.
LABORATORIES ON ADMISSION: Hematocrit of 41.3. He had a
sodium of 150. His creatinine was normal at 0.7. His INR
was 0.9.
X-RAYS: His CT of his head revealed small amount of subdural
blood with a small amount of subarachnoid blood. There were
no bony abnormalities. There was no midline shift.
CT of the C spine was negative. CT of his abdomen and pelvis
is negative.
His TLS films: There was a question of L5-S1 anterolisthesis
old versus new. His right humerus film was negative. His
right wrist film was negative.
Chest x-ray was negative as was his pelvis x-ray.
HOSPITAL COURSE: The patient was admitted on [**2201-5-2**] to the
Intensive Care Unit for q1h neurologic checks. He was seen
in consultation by Neurosurgery, who recommended a MRI of his
brain with gadolinium on hospital day one to assess for bleed
versus meningeoma. They also recommended a MRI of his spine
given the abnormalities on his TLS film.
The patient's original ICU course was significant for
tachycardia, which was thought to be secondary to DT's. This
was treated with a CIWA protocol. The patient also required
intubation for his MRI given his severe agitation and
inability to remain still. The patient went for his MRI,
which revealed likely old L5-S1 anterolisthesis and
spondylosis. The MRI of his C spine was negative as well.
His C collar was removed and his TLS was cleared.
The patient was extubated. He continued to do well, and was
transferred on the floor. On the floor, he continued to have
significant confusion. He was seen in consultation by the
Neurology team, and they felt that maybe he was withdrawing
from his Ativan, and therefore his Ativan dose was increased.
He also had some respiratory issues including a bout of
stridor as well as low sats. His chest x-ray did show a
question of a right lower lobe infiltrate versus atelectasis,
however, his ABGs were normal and the patient continued to
saturate well. He was treated with Decadron and racemic epi
for his stridor, which improved and his nasogastric tube was
removed, which had been giving him tube feeds.
The patient did improve somewhat, however, on [**2201-5-16**], the
patient was found in his room with a heart rate in the 30s,
unresponsive. A code was called and the patient was
resuscitated. He was intubated and transferred to the
Intensive Care Unit, where a central venous line was placed
and he was resuscitated for a low CVP.
Also of significance, the patient did have a urine culture,
which is positive for Staph and Enterococci as well as one
positive blood culture. Originally these were both treated
with vancomycin, however, when they came sensitive to
Levaquin, his antibiotics were changed.
His ICU course was significant for the fact that the patient
self extubated on [**2201-5-18**]. He did well with this, however,
and did not require intubation. His last day in the unit was
essentially otherwise uneventful. He continued to improve.
His confusion cleared, and his Ativan was weaned. He did
undergo a swallow evaluation on [**2201-4-21**], which revealed some
coughing with liquids as well as soft solids, so it was
decided to continue him NPO.
At discharge, the plan is to either continue the TPN and
allow the patient to re-undergo a swallow evaluation at rehab
or to likely place a Dobbhoff versus a PEG for tube feeds.
The patient was seen in consultation by ENT given his small
amount of stridor, and they did not see any anatomic
abnormality, however, they did see some minimal erythema. It
was felt that the patient should be on Protonix b.i.d. for
likely reflux. The patient is stable at discharge.
He should follow up with Neurosurgery as well as in the
Trauma Clinic. We will place the exact follow-up
instructions in the page one.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Ativan 0.5 mg IV q.h.s. prn insomnia.
2. Protonix 40 mg IV q.12h.
3. Lopressor 5 mg IV q.6h.
4. Levofloxacin 500 mg IV q.24h. for a total of 10 days.
This will end on the [**2-23**]. Regular insulin-sliding scale.
6. Heparin 5000 units subQ b.i.d.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern1) 56208**]
MEDQUIST36
D: [**2201-5-22**] 09:09:08
T: [**2201-5-22**] 09:30:38
Job#: [**Job Number **]
ICD9 Codes: 5180, 486, 5990, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4780
} | Medical Text: Admission Date: [**2162-10-3**] Discharge Date: [**2162-12-1**]
Service: MEDICINE
Allergies:
Opioid Analgesics / Iodine; Iodine Containing / Nitrostat
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
"Weakness all over my body"
Major Surgical or Invasive Procedure:
[**10/2162**]: Vtach/vfib arrest s/p cardioversion now on chronic
amiodarone therapy
[**2162-10-25**]: Percutaneous gastrostomy tube placement.
[**2162-10-25**]: Open tracheostomy tube placement.
[**2162-10-29**]: Flexible bronchoscopy with therapeutic aspiration
of bloody secretions.
Ultrafiltration with removal of 18L of fluid
History of Present Illness:
84 yo male with multiple medical problems, including
hypertension, hypercholesterolemia, CAD, and history of CVA's
who presented to the ED with a 24 history of weakness, cough,
SOB and nausea. He denied fevers, chills, chest pain, abdominal
pain. Emesis x 1 that AM. In ED he was found to be hypoxemic w/
sats 85% on RA, pulmonary edema on CXR and SBP in the 80's. On
presentation, however, the patient was alert and oriented,
appropriate and mentating well. He initially received 2L NS for
IVF hydration, as well as antibiotics including ceftriaxone,
azithromycin, vancomycin for suspected community acquired
pneumonia. The patient then went into rapid afib with HR in the
140's. He was given 5 mg Lopressor IV and his HR decreased to
100. However, the patient's respiratory status declined
precipitously and his sats dipped to 86% on a 100% face mask. He
was placed on a nonrebreather and subsequently intubated in the
setting of impending respiratory failure. Peri-intubation the
patient again became hypotensive with SBP in the 80-60's and was
started on dopamine and dilt for rate control. After intubation
and central line placement, the patient was transferred to the
MICU and admitted with a running diagnosis of sepsis caused by
an underlying community acquired pneumonia.
Although the patient had a extensive medical history and problem
list, prior to presentation and subsequent admission to the
hospital he was fairly independent and ambulatory, living at
home with his wife.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Acromegaly since [**2108**]
4. Transient ischemic attacks in [**2129**] and [**2146**] and [**2155**]
5. Subacute bacterial endocarditis
6. High-grade ventricular ectopy
7. Status post prostate surgery in [**2140**]
8. Squamous cell carcinoma
9. CAD w/ PTCA of LAD in [**2160**]
10. Hernia in [**2146**] with recurrence in [**2154**]
11. Paget's disease in [**2148**]
12. Hyponatremia in [**2148**]
13. Mitral regurgitation
14. Polymyalgia rheumatica
15. Macular degeneration in the right eye in [**2153**]
16. Prosthesis in the left eye since [**2149**]
17. History of dizziness and motion sickness/falls
18. History of pituitary tumor, s/p resection with resulting
panhypopituitarism requiring chronic steroid therapy
Social History:
Married, worked as an accountant, no tobacco x 45 years, minimal
ETOH.
Son who lives in [**Location 3340**], Daughter who lives in [**Country **].
Family History:
Mo died 79 of CVA, Fa died at 90 of "old age", sister died 47 of
breast cancer
Physical Exam:
[**2162-10-4**] on admission from ED to MICU
Temp 99.1, HR 70, BP 90's/palp, (101/53 on dopamine), sats 97%
on AC, TV 550, RR16, PEEP 5 FiO2 70
GENL: elderly male, sedated, intubated
HEENT: L eye prosthetic, R eye minimally reactive, no icterus,
no JVP, no LAD, Left IJ TLC in place
CV: distant HS, + very loud holosystolic murmur heard throughout
the chest with PMI at the apex and radiation to the left axilla
Lungs: End exp wheezes at apices, clear with decreased movement,
crackles at bilateral bases
ABD: soft, obese, non-distended, +BS, no HSM
EXT: 1+DP pulses, WWP, minimal edema
Pertinent Results:
CTA CHEST W&W/O C &RECONS [**2162-10-4**] 1:24 PM
IMPRESSION:
1. No CT evidence of pulmonary embolus.
2. Bilateral large pleural effusions with bibasilar
collapse/consolidation.
3. Multiple hepatic cysts.
TTE ECHO Study Date of [**2162-10-4**]
Conclusions:
1. The left atrium is moderately dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed.
3. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
4. The mitral valve leaflets are moderately thickened with the
posterior
leaflet be calcified and prolapsing. Mild to moderate ([**12-11**]+)
mitral
regurgitation is seen.
5. Compared with the findings of the prior report (tape
unavailable for
review) of [**2158-5-2**], left ventricular systolic function may have
decreased.
TEE ECHO Study Date of [**2162-10-6**]
Conclusions:
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%)
(intinsic LV systolic function may be depressed given the
severity of mitral regurgitation). Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild to moderate ([**12-11**]+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is moderate/severe mitral valve prolapse. There is partial
posterior mitral leaflet flail. There is a echodense mass on the
posterior leaflet consistent with probable old vegetation on the
mitral valve; small mobile echodense mass is associated that may
represent a possible new vegetation. Eccentric, anteriorly
directed, moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. No
vegetation/mass is seen on the tricuspid or pulmonic valves.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Probable old (healed) mitral valve vegetation;
cannot exclude
small superimposed new vegetation. Mitral valve prolapse with
partial flail of the posterior leaflet and moderate to severe
(3+) mitral regurgitation. Mild to moderate (2+) aortic
regurgitation. Mild to moderate (2+) tricuspid regurgitation.
Normal biventricular systolic function (LVEF 60-70%)(intrinisic
LV systolic function may be depressed given the severity of
mitral regurgitation).
ECHO Study Date of [**2162-10-10**]
Conclusions:
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. There is
partial mitral leaflet flail. Moderate to severe (3+) mitral
regurgitation is seen. Tricuspid regurgitation is present but
cannot be quantified. There is a trivial/physiologic pericardial
effusion.
Compared with the findings of the prior report (tape unavailable
for review)of [**2162-10-6**], there is no significant change
ECHO Study Date of [**2162-11-1**]
Conclusions:
1. The left atrium is normal in size.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is 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 moderately thickened. There is
partial mitral leaflet flail. Mitral regurgitation is present
but cannot be quantified.
6.There is no pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2162-10-10**], the mass on the posterior mitral valve leaflet is more
prominent. This may
represent a flailed mitral valve leaflet with chordae or it may
represent a vegetation. If the mass is a vegetation, and because
this mass appears
calcified, this mass might be a healed vegetation. The mitral
regurgitation is hard to quantify in this present study.
TEE ECHO Study Date of [**2162-11-3**]
Conclusions:
The left atrium is markedly 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. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function may be
more depressed given the severity of mitral regurgitation.]
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm, non-mobile) atheroma in the aortic
arch. The aortic valve leaflets (3) are mildly thickened, but no
aortic stenosis is present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is partial
flail of the posterior leaflet with leaflet tethering and a very
small (~2mm) mobile echodensity at the leaflet tip that likely
represents a ruptured chordae (cannot exclude a vegetation if
clinically suggested).. An eccentric jet of severe (4+) mitral
regurgitation is seen. An echodense "mass" is seen in close
proximity to the mitral annulus. This may represent a healed
abscess or
atypical mitral annular calcification. A mobile mass is seen
attached to the posterior leaflet. This may represent a torn
chordae or a healed vegetation. The tricuspid valve leaflets are
mildly thickened. No vegetation/mass is seen on the pulmonic
valve or tricuspid valve. There is no pericardial effusion.
CT CHEST W/O CONTRAST [**2162-11-5**] 11:09 AM
IMPRESSION:
1) Worsening pulmonary edema.
2) Moderate bilateral pleural effusions,which have increased
compared to [**2162-10-4**]. There is bibasilar atelectasis as
well. A pneumonia in these consolidative areas cannot be fully
excluded.
CT ABDOMEN W/O CONTRAST [**2162-11-15**] 2:48 PM
CT CHEST WITHOUT IV CONTRAST: As on the prior study, there are
large bilateral effusions, stable since the prior study. The
previously noted bilateral upper lobe air space disease has
progressed and appears more densely consolidated, particularly
within the right upper lobe, and to a lesser extent the left
upper lobe. Additionally, Hounsfield units within the areas of
dense consolidation measure up to approximately 67 Hounsfield
units, which is denser than simple fluid, indicating complex
fluid, possibly hemorrhage.
A tracheostomy tube is noted. No mediastinal adenopathy.
Bibasilar collapse is once again identified, unchanged. Mitral
valve calcifications as well as coronary calcifications are
seen. A right subclavian line is noted, with its tip in the
superior vena cava.
CT ABDOMEN WITHOUT IV CONTRAST: Multiple low-attenuation lesions
are seen within the liver, measuring up to approximately 6 cm,
probably representing cysts. A gastrostomy tube is noted.
Unenhanced gallbladder, adrenals, kidneys, and spleen appear
normal. The pancreas contains a few punctate calcifications,
with extensive calcifications noted within the splenic artery.
CT PELVIS WITHOUT IV CONTRAST: The unenhanced colon, urinary
bladder and seminal vesicles are grossly normal. An open left
inguinal ring containing fat is identified.
BONE WINDOWS: There is severe demineralization within the sacrum
and left iliac bone, with degenerative changes noted within the
remainder of the spine.
IMPRESSION: Dense consolidation within the upper lobes, which is
increased since the prior study dated [**2162-11-5**]. The
density of the consolidation suggests complex fluid and is
compatible with hemorrhage, particularly given the clinical
history.
ECHO Study Date of [**2162-11-17**]
Conclusions:
The left atrium is markedly dilated. The left ventricular cavity
size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is partial mitral leaflet flail.
There is moderate thickening/calcification of the mitral valve
chordae (no definite vegetation seen; cannot exclude
vegetation/healed vegetation). Severe (4+) mitral regurgitation
is seen. The mitral regurgitation jet is eccentric. There is no
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2162-11-1**],
there is no
significant change.
[**2162-12-1**]: Cardiac catheterization: Report pending at the time of
transfer.
Brief Hospital Course:
The patient was admitted to the MICU with a diagnosis of sepsis
and community acquired pneumonia. He had a long and complicated
hospital course that will be described by system.
1. Respiratory: The patient was intubated on the day of
admission for hypoxic respiratory failure presumably related to
sepsis and CAP in the setting of baseline CHF. In the ED, the
patient received a dose of ceftriaxone, azithromycin, and
vancomycin. He was initially continued on Vancomycin and also
started on Levaquin for ABx coverage for presumed community
acquired pneumonia. Blood cultures drawn on the date of
admission [**10-4**] showed 1/2 bottles positive for Staph Coag Neg.
Further blood cultures were negative. He then developed
ventilator associated pneumonia with MRSA. He was given
Linezolid for coverage of MRSA and completed a 2-week course on
[**2162-10-25**]. He required trach placement on [**2162-10-25**] for failure
to wean. His sputum cultures were repeatedly positive for MRSA
and pseudomonas and enterobacter cloacea througout his
hospitalization. He was treated with vancomycin and meropenem
from [**2162-10-31**] through [**2162-11-13**]. The vancomycin was restarted on
[**2162-11-15**] after he spiked a fever and had MRSA in sputum again and
this was continued until his discharge. He was started on
ceftazidime on [**2162-11-23**] and that was also continued until his
discharge. He was also treated with Flagyl early in the
hospitalization for presumed aspiration pneumonia. Most recent
sputum cultures from [**2162-11-29**] were positive for MRSA and
pseudomonas sensitive to ceftazidime. His latest ventilator
settings were AC/0.4/TV=600/RR=10/PEEP=5. He had repeated trials
with a Passy-Miur valve that were unsuccessful leading to
coughing fits.
2. CV: The patient was initially hypotensive at the time of
admission, likely related to sepsis +/- possible adrenal
insufficiency. On admission, he was started on stress dose
steroids and overnight remained on dopamine. The patient was
able to be weaned off pressors after the first night, but
subsquently required intermitent use of pressors to maintain his
SBP.
2.1. Rhythm: He was in afib with a rapid ventricular response on
admisison that was treated with a diltiazem drip, lopressor and
digoxin. He developed polymorphic VT with a transition to Vfib
on [**2162-10-23**] that responded to defibrillation. He was started on
a lidocaine drip and then switched to amiodarone. The amiodarone
dose was decreased on [**2162-11-28**] in attempt to decrease the beta
blocker effect in the face of CHF. He is to remain on Amiodarone
200 mg PO daily. He also went into atrial fibrillation early in
the hospital course that resolved with discontinuation of
dobutamine. He was in normal sinus rhythm at the time of
discharge.
3. Mitral Regurgitation: Per echo he has 4+ MR, which has been
refractory to medical therapy. Fluid overload was a major issue.
He underwent ultrafiltation in the CCU for several days with
removal of 18L of fluid. Upon completion of ultrafiltration he
was diuresed unsuccessfully with lasix boluses. He was started
on a lasix drip with a goal of even to negative fluid balance.
However, we were limited given his hypotension and had to be
held frequently. His blood pressure also did not tolerate
nesiritide. Captopril was added at a dose of 12.5 mg TID for
afterload reduction, along with Lasix drip as tolerated by BP.
Digoxin was also added for inotropic effect. Close to discharge,
the patient was tolerating captopril plus intermittent lasix
drip of 2mg/hr titrated to blood pressure. The lasix drip was
converted to a standing dose of 40mg IV BID. Metolazone 5mg po
BID was also added for synergy. Pt did well on this regimen x
48hrs prior to the time of discharge. Pt was initially informed
that he may be candidate for MV replacement surgery, but was
subsequently refused this surgery by the CT [**Doctor First Name **] service who
felt that his operative risk was too high given his significant
comorbities.
4 History of endocarditis ([**2127**]'s): TEE showed a question of a
vegetation on MV. Subsequently, low suspicion.
5. Agitation: Pt was kept on a standing dose of haldol 2.5 mg
TID which was effective.
7. Nutrition: Mr. [**Known lastname **] has a PEG tube and was tolerating tube
feeds using Respalor Full strength at 50cc/hr. Vit C and Zinc
were added per nutrition recommendations.
8. Endocrine: Mr. [**Known lastname **] has known panhypopituitarism. He was
admitted on prednisone 5 mg daily (home dose). He required
stress dose steroids for his adrenal, subsequently tapered to 20
mg PO daily, on which he remains at the time of discharge.
Regarding his diabetes, serum glucose was well controlled on an
insulin sliding scale starting with 5 units for FSG > 150 and
incrementing by 2 units.
9. Hematology: He had thrombocytopenia initially on admission.
HIT antibody was negative. His thrombocytopenia was subsequently
attributed to Linezolid, and resolved several days after
linezolid was discontinued. Platelet count 170s on day of
discharge.
10. Prophylaxis: Pt was treated with Carafate for GI prophylaxis
(given thrombocytopenia) and Heparin SQ for DVT prophylaxis.
11. Physical Therapy: Pt was felt to be progressing well from a
PT standpoint. He will need continued aggressive PT follow-up.
12. Access: A right subclavian was placed on [**2162-11-14**] and a PICC
line was placed on [**2162-11-30**].
Medications on Admission:
Metoprolol 12.5 mg [**Hospital1 **]
ECASA 325 mg daily
Plavix 75 mg daily
Folic acid 2 mg [**Hospital1 **]
Zocor 30 mg QHS
Vit B6 100 mg daily
Vit B12 100 mcg daily
CaCO3
MVI
Meclizine prn
Vitamin E
Prednisone 5 mg daily
Temezepam prn
Discharge Medications:
1. Furosemide 40 mg IV BID
2. Heparin 5000 UNIT SC TID
3. Metolazone 5 mg PO BID
4. Vancomycin HCl 1000 mg IV Q24H (Please hold Vanco for random
level >20)
5. Meclizine HCl 12.5 mg PO Q8H:PRN
6. Amiodarone HCl 200 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Ceftazidime 2 gm IV Q8H [**11-23**]
9. Captopril 12.5 mg PO TID (Hold for MAP<50) [**11-20**]
10. Ascorbic Acid 500 mg PO BID [**11-19**]
11. Zinc Sulfate 220 mg PO DAILY [**11-19**]
12. Morphine Sulfate 2-4 mg IV Q2H:PRN [**11-18**]
13. Psyllium 1 PKT PO TID:PRN [**11-16**]
14. Haloperidol 2.5-5 mg IV BID:PRN agitation [**11-14**]
15. Haloperidol 2.5 mg PO TID [**11-14**]
16. Oxybutynin 5 mg PO BID:PRN [**11-13**]
17. Insulin SC (per Insulin Flowsheet)
18. Bisacodyl 10 mg PO/PR [**Hospital1 **]:PRN (hold for diarrhea) [**11-10**]
19. Lactulose 30 ml PO Q8H:PRN (hold for diarrhea) [**11-10**]
20. Senna 1 TAB PO BID:PRN (hold for diarrhea) [**11-10**]
21. Nystatin Oral Suspension 5 ml PO QID:PRN [**11-10**]
22. Miconazole Powder 2% 1 Appl TP QID groin [**Female First Name (un) **] [**11-10**]
23. Milk of Magnesia 30 ml PO Q6H:PRN [**11-10**]
24. Simethicone 40-80 mg PO QID:PRN [**11-10**]
25. Acetaminophen 325-650 mg PO Q4-6H:PRN [**11-10**]
26. Sucralfate 1 gm PO QID [**11-10**] @ 2126 View
27. Prednisone 20 mg PO DAILY [**11-10**]
28. Cyanocobalamin 1000 mcg PO QD [**11-10**]
30. Docusate Sodium (Liquid) 100 mg PO BID
31. Simvastatin 30 mg PO QHS
32. Folic Acid 3 mg PO BID
33. Thiamine HCl 100 mg PO/NG DAILY
34. Artificial Tears 1-2 DROP OU PRN
35. Albuterol-Ipratropium [**12-11**] PUFF IH Q4H:PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1)Respiratory failure
2)Congestive heart failure
3)Mitral regurgitation
4)Community-acquired pneumonia
5)Ventilator associated pneumonia
6)Tracheostomy
7)Anemia
8)Thrombocytopenia
9)Hypopituitarism
Discharge Condition:
Fair
Discharge Instructions:
To [**Hospital6 **]
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **]
Completed by:[**2162-12-1**]
ICD9 Codes: 4240, 4280, 5070, 5119, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4781
} | Medical Text: Admission Date: [**2193-10-15**] Discharge Date: [**2193-10-20**]
Date of Birth: [**2110-4-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
83 year old female with post-traumatic left hip OA
Major Surgical or Invasive Procedure:
[**2193-10-15**] Left hip hardware removal, total hip arthroplasty
History of Present Illness:
83 year old female with post-traumatic left hip OA
Past Medical History:
Atrial fibrillation, hypertension, hypothyroidism, osteoporosis
Social History:
NC
Family History:
NC
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
Labs on admission:
[**2193-10-16**] 01:13AM BLOOD WBC-14.2*# RBC-3.24* Hgb-9.8* Hct-29.3*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.7 Plt Ct-144*
[**2193-10-16**] 01:13AM BLOOD PT-13.2 PTT-25.4 INR(PT)-1.1
[**2193-10-16**] 01:13AM BLOOD Glucose-101 UreaN-22* Creat-1.3* Na-139
K-5.5* Cl-106 HCO3-19* AnGap-20
[**2193-10-16**] 01:13AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.5* Iron-61
[**2193-10-16**] 01:13AM BLOOD calTIBC-208* Ferritn-143 TRF-160*
Cardiac enzymes:
[**2193-10-16**] 05:06AM BLOOD CK-MB-7 cTropnT-0.02*
[**2193-10-16**] 04:38PM BLOOD CK-MB-9 cTropnT-0.02*
[**2193-10-17**] 04:20AM BLOOD CK-MB-8 cTropnT-0.02*
[**2193-10-17**] 10:40AM BLOOD CK-MB-7 cTropnT-0.01
Labs prior to discharge:
Brief Hospital Course:
The patient was admitted on [**2193-10-15**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) 5322**] for left hip DHS
removal and primary total hip arthroplasty without complication.
Please see operative report for details. Postoperatively the
patient did well. The patient was initially treated with a PCA
followed by PO pain medications on POD#1. The patient received
IV antibiotics for 24 hours postoperatively, as well as lovenox
for DVT prophylaxis starting on the morning of POD#1. The drain
was removed without incident on POD#1. The Foley catheter was
removed without incident. The surgical dressing was removed on
POD#2 and the surgical incision was found to be clean, dry, and
intact without erythema or purulent drainage.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to home with
services or rehabilitation in a stable condition. The patient's
weight-bearing status was WBAT LLE with posterior precautions.
[**Hospital 153**] Hospital Course:
Ms. [**Known lastname 1968**] is an 83 yo F with PMH atrial fibrillation, s/p left
hip replacement admitted to the MICU for respiratory depression
s/p getting morphine for pain and agitation in the PACU.
.
#Respiratory depression: was most likely [**3-11**] morphine given
postoperatively in the setting of baseline renal insufficiency.
On arrival to the ICU she is maintaining her respiratory rate
and ABG with normal CO2. CXR showed no edema, pleural
effusions, vascular congestion.
.
#Hypotension: she has borderline hypotension on arrival to the
ICU (recent bp in clinic 90/60), likely 2/2 blood loss in the
OR, volume depletion and afib with rvr.
Pt received 2U PRBC for post op anemia and then another 2U the
day after for a drop in Hct. Hypotension resolved following
appropriate volume resuscitation.
.
#Afib wit RVR: likely [**3-11**] operative stress/medication, new
anemia. Pt was monitored on the tele. Pt was relateively
rate-controlled on Metoprolol Tartrate 37.5mg PO QID.
Pt placed on lovenox for anticoagulation and bridged to
Coumadin. Patient therapeutic at the time of discharge. TTE
was unremarkable. She needs to be on propanolol 80mg [**Hospital1 **] per
[**Female First Name (un) 1634**] Med not metoprolol when she goes to rehab.
.
#s/p left hip replacement: was doing well post op. On Tylenol,
Lidocaine patch, and low dose oxycodone for pain control. xrays
showed good component position.
.
#agitation: was given Haldol PRN, standing seroquel. Geriatrics
service was consulted who raised the consideration that she also
might be suffering from mild etoh withdrawal. This cold also
explain her tachycardia. She was therefore started on low dose
ativan.
.
#chest pain: brief, fleeting. No EKGs changes. troponins flat.
Medications on Admission:
Aspirin, calcium, felodipine, levothyroxine, propranolol,
raloxifene, Coumadin, and valsartan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR [**3-12**].
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for distress.
15. Lorazepam 0.25 mg IV BID:PRN distress
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left hip post traumatic OA
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by Dr. [**Last Name (STitle) 5322**] 2 weeks after your
surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue coumadin.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by Dr. [**Last Name (STitle) 5322**] at 2 weeks post op.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment.
Physical Therapy:
WBAT LLE with posterior precautions
Treatments Frequency:
Dry sterile dressing to incision daily. Staples out by Dr.
[**Last Name (STitle) 5322**] at 2 week post op visit. Coumadin daily for INR [**3-12**]
Followup Instructions:
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2193-10-30**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2193-12-6**] 9:00
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
Completed by:[**2193-10-19**]
ICD9 Codes: 2851, 2930, 4019, 2449, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4782
} | Medical Text: Admission Date: [**2108-12-9**] Discharge Date: [**2108-12-18**]
Date of Birth: [**2046-9-8**] Sex: M
Service: SURGERY
Allergies:
Haloperidol
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy
History of Present Illness:
This man has had abdominal pain. He did not
have peritoneal findings and KUB demonstrated dilated small
bowel. CT scan demonstrated air in the portal system as well
as possibly in the small bowel wall itself. He was therefore
taken to the Operating room and placed in the supine
position. He was given general anesthetic. The abdomen was
prepped and draped using Betadine solution. The patient's
previous midline abdominal incision was reopened. It was
deepened down to subcutaneous tissue to the level of the
fascia. The fascia was opened. In the lower end of this
fascial closure, we found separate blue sutures which were
not present in the upper end of the incision, suggesting that
he, in fact, probably had 2 operations in the past. The
patient did not give that history.
Past Medical History:
PMH: Schizophrenia, Depression, DM
PSH: Ex lap and splenectomy s/p GSW [**2074**]
Social History:
B&[**Initials (NamePattern4) **] [**Location (un) 669**], middle of 6 kids, dad was an abusive
alcoholic. Pt. attended prep school. After graduation worked for
Turnpike for several years. He's been on disability for >20yrs.
Pt said he has been living in a group home in [**Location (un) **] for the
past five years.
Family History:
denies mental illness, suicides
Physical Exam:
ED
Vitals: T-100.7, HR-100, BP-120/54, RR-16, O2 sat-98% on RA
Const: NAD, A/Ox3
Head/Eyes: NCAT
Resp: CTAB
CV: RRR, + systolic murmur
ABD: distended, decreased bowel sounds
GU: no CVAT
Extrem: No edema B/L
Pertinent Results:
[**2108-12-17**] 05:28AM BLOOD WBC-12.5* RBC-3.98* Hgb-12.1* Hct-34.6*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.6 Plt Ct-264
[**2108-12-17**] 05:28AM BLOOD Neuts-83.5* Lymphs-11.2* Monos-4.8
Eos-0.4 Baso-0.1
[**2108-12-9**] 01:45PM BLOOD WBC-25.9* RBC-4.91 Hgb-15.1 Hct-42.5
MCV-87 MCH-30.8 MCHC-35.6* RDW-14.0 Plt Ct-208
[**2108-12-10**] 03:21AM BLOOD PT-13.1 PTT-25.4 INR(PT)-1.1
[**2108-12-9**] 01:45PM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.2*
[**2108-12-17**] 05:28AM BLOOD Plt Ct-264
[**2108-12-17**] 05:28AM BLOOD Glucose-180* UreaN-7 Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-26 AnGap-10
[**2108-12-9**] 01:45PM BLOOD Glucose-226* UreaN-30* Creat-1.0 Na-142
K-4.2 Cl-105 HCO3-25 AnGap-16
[**2108-12-13**] 07:44PM BLOOD CK(CPK)-417*
[**2108-12-13**] 08:18AM BLOOD CK(CPK)-548*
[**2108-12-13**] 12:42AM BLOOD CK(CPK)-688*
[**2108-12-11**] 02:28AM BLOOD ALT-21 AST-23 AlkPhos-75 Amylase-14
TotBili-0.3
[**2108-12-13**] 07:44PM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-12-9**] 09:36PM BLOOD CK-MB-4 cTropnT-<0.01
[**2108-12-17**] 05:28AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9
[**2108-12-9**] 09:36PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9
[**2108-12-9**] 01:45PM BLOOD Albumin-4.2
[**2108-12-13**] 12:38AM BLOOD Lactate-1.4
[**2108-12-9**] 01:56PM BLOOD Lactate-2.2*
.
Blood cultures-negative
Urine cultures-negative
MRSA cultures-negative
.
RADIOLOGY Final Report
CT PELVIS W/CONTRAST [**2108-12-9**] 5:18 PM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with sbo on xray, abd pain and elevated wbc
IMPRESSION:
Large amount of diffuse portal venous gas seen within the liver,
out of proportion to possible small amount of pneumatosis.
Multiple abnormally dilated loops of small bowel with
decompressed bowel distally. Findings are consistent with
ischemic bowel, possibly from obstruction. Possible transition
point is seen in the right lateral abdomen at the distal ileum.
Findings were discussed with the clinical team immediately
following completion of the study.
.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) PORT [**2108-12-9**] 1:17 PM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with upper abd pain, ?ekg changes
REASON FOR THIS EXAMINATION:
eval for SBO (upright, please)
IMPRESSION: Markedly distended small bowel loops that may be
secondary to an SBO, likely distal in origin given the number of
distended small bowel loops. Ileus is also a consideration.
Clinical correlation and/or cross-sectional imaging is
recommended.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97323**]Portable TEE
(Complete) Done [**2108-12-9**] at 9:24:43 PM FINAL
Conclusions
The left atrium is mildly dilated. No mass/thrombus is seen in
the left atrium or left atrial appendage. . Color-flow imaging
of the interatrial septum raises the suspicion of an atrial
septal defect, but this could not be confirmed on the basis of
this study. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size is mildly dilated, free wall motion are normal. The
aortic valve leaflets are moderately thickened. Significant
aortic stenosis may be present (not quantified) due to technical
limitations .Bicuspid aortic valve cannot be ruled out . No
aortic regurgitation is seen.Ascending aorta is mildly dilated
,descending thoracic aorta normal in diameter. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97323**]Portable TTE
(Complete) Done [**2108-12-10**] at 10:30:27 AM FINAL
Conclusions
The left atrium is normal in size. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis (area 1.0-1.2cm2). The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with overall
normal function. Moderate aortic stenosis.
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2108-12-13**] 1:43 AM
Reason: r/o PE
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p ex lap for ischemic bowel POD #4, with
intra-op ST depressions; now with new onset mental status
changes, hypoxia, tachypnea.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bibasilar infiltrates, consistent with aspiration.
3. Small amount of portal venous gas remains.
.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2108-12-16**] 1:51 PM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p ex lap for ischemic bowel, no resection, now
with abdominal distension
IMPRESSION: Non-specific bowel gas pattern. While the findings
can be seen with ileus, differential air-fluid levels are
atypical for ileus. Close clinical followup is recommended.
Brief Hospital Course:
Mr. [**Known lastname 496**] presented to ED via ambulance from group home for
evaluation of abdominal pain w/ N/V x 6 days. EKG in ED revealed
T wave inversions. CT scan revealed small bowel obstruction, and
extensive portal venous air. Due to clinical presentation,
elevated WBC, and no recent h/o colonoscopy, surgery
intervention was deemed necessary per General Surgery Service.
.
Mr. [**Known lastname **] operative course was complicated by ST segment
changes via EKG. He was stabilized,and surgery was successfully
completed.
.
POD1/ICU: Transferred to ICU due to noted bowel changes intra-op
and cardiac instability where he remained intubated. His cardiac
enzymes were cycled with no increase in troponin levels, and was
ruled out for a myocardial infarction. In addition, an
Echocardiogram revealed no thrombus or wall motion abnormality.
BP elevation 140-150 systolic was managed briefly with IV Nitro,
discontinued once BP's stabilized. Cardiology was consulted.
Continued with beta-blockade. Bowel ischemia thought to be
vascular in nature. No abdominal cause for
obstruction/hypoprofusion noted via Ex/Lap. He was started on IV
Levo & Flagyl.
.
POD2/ICU: Extubated with no event. Pain managed with IV Dilaudid
PCA. Received LR boluses for low urine output. Started on sips
for comfort. His condition remained stable, and he was
transferred to [**Hospital Ward Name **] for post-op care. Psych was consulted for
management of medications. Recommended continuation of home
regimen, and cleared for discharge back to group home once
stable.
.
POD3/FA9/ICU: NGT was removed. He was confused overnight with
complaints of pain. His O2 sats decreased to 80-90's resulting
in a "Trigger". ABG revealed PO2-64, and EKG with ST depressions
once again. He was transferred back to ICU. CT was obtained
which was negative for PE. CXR revealed mild fluid overload. He
was transferred back to the ICU for management of possible
ischemic cardiac episode. Enzymes were flat, and patient was
asymptomatic during event. CT was negative for PE.
.
POD4/ICU/FA9: He was monitored overnight in ICU, remained
stable, and was transferred back to [**Hospital Ward Name **].
.
POD5-Discharge [**2108-12-18**]: His diet was advanced to regular food as
tolerated. He resumed all his home medication, and tolerated
oral pain medication. Due to his cardiac event, cardiology
recommended continuation of Lopressor and aspirin. Prescriptions
were faxed to pharmacy, and regimen changes was discussed with
[**Doctor First Name **] & [**Doctor Last Name **] from Bay Cove group home. His Foley catheter was
removed, and he was able to urinate without difficulty. His
abdomen is large, appropriately tender with active bowel sounds.
His incision is OTA with staples which will be removed at his
follow-up appointment with Dr. [**Last Name (STitle) **]. Distention decreased,
and he reported passing flatus, and bowel movement prior to
discharge. He ambulated the halls independently. No need for
PT/OT. VNA was arranged for home visit upond discharge to assess
incision and blood pressure. He was advised to follow-up with
his PCP for further management of blood pressure & CV status.
THis was also discussed with [**Doctor First Name **] from group home.
Medications on Admission:
clozaril, zocor, klonopin, flomax, terazosin, humalog 75/25
18qAM 28qPM
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*35 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
7. Clozapine 100 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
8. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 27
units Subcutaneous QPM.
9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 18
units Subcutaneous QAM.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Invega 3 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
14. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
pneumatosis
Small bowel obstruction
Ischemic bowel
Post-op pulmonary edema
.
Secondary:
Schizophrenia, Depression, DM
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please make a follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **] in [**1-13**]
weeks.
2. Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12806**],
[**Telephone/Fax (1) 97324**] in 1 week or as needed.
Completed by:[**2108-12-18**]
ICD9 Codes: 9971, 5070, 311, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4783
} | Medical Text: Admission Date: [**2130-12-21**] Discharge Date: [**2130-12-27**]
Date of Birth: [**2066-2-9**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin/Sulfisoxazole
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
multiple external cardioversions
intra aortic balloon pump
foley catheter
venous sheath
arterial sheath
endotracheal intubation
oral gastric tube
History of Present Illness:
Mr. [**Known lastname **] is a 64 y/o M with a history Ichemic CM with a
history of VTach s/p ICD placement, s/p three prior ablations.
The patient has a history of [**Hospital1 **]-monthly episodes of syncope
associated with appropriate ICD firing. Over the past two days,
the patient states that his ICD has fired while he is conscious.
Pt stated that two days ago his ICD fired three times, then
fired another two times yesterday, and then once more this
evening that led him to seek medical attention in the ER. The
patient has been on Meiiletine and Dofetilide, and the plan has
been for patient to switch to dronetarone as patient has failed
prior medical therapy.
In the ED, the patient's VS were 98 69 130/63 16 99%RA. EKG AV
paced similar to prior. EP was consulted and recommended
admission. Interrogation revealed slow VT at 140s, patient's
settings were not changed this evening. Labs only notable for K
3.9. Recevied 40mEq PO KCl. On transfer, VS were Afeb, 70,
107/57, 16, 100% RA.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
Asthma
GERD
Anxiety
CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
CARDIAC HISTORY:
-CABG: CAD s/p CABG x 5 '[**18**]
-PERCUTANEOUS CORONARY INTERVENTIONS: Unk
-PACING/ICD:
h/o VT and VF s/p ICD in [**2124**]
BiV upgrade in [**2126**]
s/p VT ablation procedures in [**2128-7-9**] and [**2129-6-9**],
LVEF 15-20%, left ventricular aneurysm,
Severe infarct related myopathy
Social History:
Tobacco 1.5ppd x 20 yrs, quit in [**2091**]. occ ETOH. No drugs,
married
Family History:
+ DM, +CAD No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: 97.8, 118/74, 70. 18, 98%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP 8cm.
CARDIAC: Inferolaterally displaced, RR, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NT. Mild abdominal distention. No HSM or
tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
-----------------
VS upon discharge:
T 98.2 HR 70 AV paced 95/38 with IABP set to 1:1 RR 20 O2sat 99%
Vent settings: AC 500 x RR 20 x 5 PEEP FiO2 40%
-failed pressure support trial because of oversedation
Pertinent Results:
Admission Labs:
[**2130-12-21**] 09:15PM WBC-9.6# RBC-4.34* HGB-12.6* HCT-36.7* MCV-84
MCH-29.1 MCHC-34.4 RDW-14.7
[**2130-12-21**] 09:15PM PLT COUNT-187
[**2130-12-21**] 09:15PM GLUCOSE-109* UREA N-25* CREAT-1.3* SODIUM-137
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-33* ANION GAP-12
[**2130-12-21**] 09:15PM cTropnT-0.01
[**2130-12-21**] 09:15PM CK(CPK)-43
[**2130-12-21**] 09:15PM CK-MB-NotDone
[**2130-12-21**] 09:15PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2130-12-21**] 09:15PM PT-24.3* PTT-25.7 INR(PT)-2.3*
ECG: A-V sequential paced rhythm. Premature ventricular
contraction or fusion
beat. Compared to the previous tracing of [**2129-6-29**] the
ventricular premature
beat or fusion beat is new.
TTE [**12-26**]: The left atrium is markedly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
severely dilated. There is severe global left ventricular
hypokinesis with some preservation of the basal septal wall
(LVEF = [**11-23**] %). The inferior and inferolateral walls are
thinned and akinetic. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild to moderate ([**2-10**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Severe dilated left venticular cardiomyopathy with
akinesis of the inferior and inferolateral walls and hypokinesis
of the remainder of the ventricle. Mild right ventricular
dilation with moderate global hypokinesis. Mild to moderate
mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2126-3-8**], the left ventricle is more dilated,
and systolic function is more impaired.
CXR [**12-26**]: FINDINGS: In comparison with the study of [**2129-6-22**],
the endotracheal tube tip lies approximately 8.2 cm above the
carina and is at the mid clavicular level.
Pacemaker device is in place. Continued substantial enlargement
of the
cardiac silhouette with minimal prominence of interstitial
markings consistent with mild elevation of pulmonary venous
pressure. No evidence of pleural effusion or acute pneumonia.
Of incidental note is prosthetic right shoulder.
[**12-26**] Cath lab: placement of IABP
Brief Hospital Course:
64 year old male with a history of ischemic CM and VTach s/p ICD
placement with three prior ablations p/w VT storm.
# VT storm: He has had three failed VT ablations in the past and
on admission, interrogation of his ICD showed slow VT with
appropriate firing of his ICD. He was on mixiletine and Tikosyn
on admission, and had been in the process of getting insurance
approval for dronedarone. His digoxin was stopped on admission
and his was monitored on telemetry. He had multiple episodes of
VTach on the floor with ICD firing and he had some transient
hypotension treated with IV fluid bolus. He was transferred to
the CCU for an amiodarone load and drip. At that time, the
excess fluid given via bolus earlier was diuresed off. The
patient continued to experience recurrent runs of ventricular
tachycardia on amiodarone, though the frequency began to
decrease. Once his loading was complete and the drip stopped,
the patient again had recurrent VT several times an hour(with
ICD firing). The patient was bolused with lidocaine, started on
lidocaine gtt, and restarted on amiodarone gtt.
.
The patient continued to experience runs of ventricular
tachycardia causing hemodynamic instability at slower rates
(110s-120s) than before (140s-160s). The patient was electively
intubated and an intra-aortic balloon pump was placed. It was
determined that the VT storm was refractory to medical
management and the next best course of action would be heart
transplant.
.
The patient had been previously screened at [**Hospital1 2025**] for cardiac
transplantation. Given his current clinical situation, he would
likely be at the top of the list for transplant. The case was
discussed amongst Drs. [**Last Name (STitle) **], [**Name5 (PTitle) 437**], as well as physicians
at [**Hospital1 2025**], and it was decided that the patient would benefit from
transfer as soon as medically stable.
.
# Coronaries: His cardiomyopathy is related to ischemia. It is
not clear whether his VT represents a new scar-mediated focus.
He was continued on a statin and aspirin. His beta-blocker and
ACEI were held in the setting of hemodynamic instability.
.
#. Code Status: He was FULL CODE during this hospitalization.
Medications on Admission:
Tikosyn 0.5mg [**Hospital1 **]
Mexiletine 200mg TID
Niasapn 500mg [**Hospital1 **]
Inspra 50mg qHS
Altace 10mg daily
Dig 125mcg daily
Coreg 25mg [**Hospital1 **]
Mag 500mg qHS
Fish Oil 100mg qHS
Lipitor 20mg daily
Torsemide 60-100mg daily
Ativan 2mg TID
Prilosec 20mg daily
Flomax 0.4mg daily
Effexor 37.5mg daily
Trazodone 100mg daily
Flonase
Combivent prn
Coumadin 2.5mg daily (except M & F - takes 5mg)
ASA 81mg daily
Potassium 20meq prn
MVI
Biotin 500mcg qHS
Selenium 200 mcg qHS
L-Carnitine 250mg qHS
Alpha lipoic acid 100mg daily
COQ10 [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Torsemide 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
5. Eplerenone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Venlafaxine 37.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a
day).
8. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 100-500 mcg
Injection INFUSION (continuous infusion): titrate to sedation.
10. Midazolam 5 mg/mL Solution [**Hospital1 **]: 5-20 mg Injection TITRATE TO
(titrate to desired clinical effect (please specify)): sedation.
11. Phenylephrine HCl 10 mg/mL Solution [**Hospital1 **]: 0.5-5 mcg/kg/min
Injection TITRATE TO (titrate to desired clinical effect (please
specify)): MAP>65.
12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**2-10**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB, wheeze.
13. 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.
14. 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.
15. Amiodarone 1 mg/min IV INFUSION
16. Heparin (IABP) 3 ml/hr IV INFUSION
For Intra-aortic Ballon Pump Administration Only
17. Heparin, Porcine (PF) 100 unit/mL Solution [**Month/Day (2) **]: dose for PTT
50-70 units Intravenous continuous infusion.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Lidocaine 2 mg/min IV INFUSION
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Ventricular Tachycarida
Ischemic Dilated Cardiomyopathy
Cardiogenic Shock
Discharge Condition:
transport to [**Hospital1 2025**] with aortic ballon pump in place, not requiring
any pressor agents, intubated and sedated on versed and fentanyl
Discharge Instructions:
You were seen at [**Hospital1 18**] for recurrent ventricular tachycardia.
Your clinical situation worsened during your hospitalization and
you required elective intubation and sedation in efforts to
control your ventricular tachycardia. An intra-aortic balloon
pump was placed in order to lessen the demands of your heart in
order to decrease the abnormal heart rhythm.
After discussion amongst our staff, it is felt that your best
option at this time is heart transplant. As you had been
screened previously at [**Hospital1 2025**] for heart transplant, we discussed
your clinical situation with the physicians there and agreed
that you should be transferred there to await transplant.
Followup Instructions:
You have the following appointments scheduled for you.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2131-3-2**] 3:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2131-3-2**]
2:00
ICD9 Codes: 4271, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4784
} | Medical Text: Admission Date: [**2142-11-19**] Discharge Date: [**2142-12-1**]
Service: NEUROLOGY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
OSH Transfer for AMS and ? seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 RHM with PMH of afib currently not on coumadin due to IPH in
[**2142-8-9**], was transfered from OSH.
His neurological problems began in [**2142-8-9**]. Before that, he
was
independent in ADLs and was high functioning. He had acute HA
and
left arm numbness/weakness for which he was taken to [**Hospital1 2025**] where
he
was found to have right temporal bleed. He was managed
conservatively and was dced in late [**Month (only) 205**] to rehab. The Coumadin
was stopped and keppra was added 750 [**Hospital1 **]. The hospital course
was
complicated by MSSA bacteremia with negative TEE, for which he
was treated with abx for 2 weeks with recovery. At rehab he did
make good progress and was sent home on [**9-23**]. From that time,
he is with his son. per son, he did bot have any significant
neurological deficits other than generalised fatigue. He was
doing well till 3 days ago. On friday early am, aroud 3, he came
back from the restroom and as he was coming, he suddenly fell
down. He was yelling for help and was having pain in left ankle.
He sat down and could not get up. 911 was called , he was taken
to OSH where he was evaluated for UTi,PNa which were negative.
CT
head showed no acute bleed. CBC Chem 7 were normal. EKG and card
enzymes didnt show anything acute. He was however noted to be
increasingly confused, drowsy and having repeated jerking
movements of left UE and LE lasting few seconds. Per son, during
few of these movements he was talking and was responding to
voice. The concern was for seizure and small doses of ativan
were
used. He underwent MRI this am which showed 2cm AVM in right ant
temp lobe with minimal edema and enhancement. He was loaded with
dilantin 1 gram IV and trasfered to [**Hospital1 18**] for eval. In the ED,
later, he was noted to have fever 101, was increasingly
tachypneic and was on the verge of intubation. Next, neurology
was called.
While examining him, I saw an episode where he had transient
jerking of left UE and LE lasting few secs also some shaking of
RLE, though much less than Left side.
Past Medical History:
- HTN
- Lipids
- Chronic afib on coumadin till [**2142-8-9**]
- Right Temporal IPH [**2142-8-9**]
- Bovine aortic valve replaced [**2137**] [**Hospital1 2025**]
- Remote h/o seizure ds, not on AEDs for last 6yrs, details not
known at this point
Social History:
Lives with son, was very high functioning before [**2142-8-9**].
Denies smoking or alcohol use. antique design expert
Family History:
? h/o brain AVM in nephew
Physical Exam:
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: Irre Irre, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neuro:
Drowsy and Inattentive.
No sponataneus verbal output. Responds minimal to verbal
commands. opens eye to painful sternal rub but closed again.
Inconsistently follows few commands to combination of verbal and
tactile stimuli. Couldnt answer any questions.
unable to assess for any apraxia or hemineglect.
Cranial Nerves:
Pupils equally round and reactive to light, 2-1
mm bilaterally. fundus difficult to evaluate
Extraocular movements intact bilaterally without
nystagmus.face appears symmetric
Motor: Normal bulk and tone bilaterally. was moving all limbs
spontaneously and to painful stimuli. withdraws to noxious
stimuli.
DTRs: 1 plus and symmetric
Toes downgoing on right and up on left
Coordination/Gait- Defd
No neck stiffness
Pertinent Results:
[**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-64*
GLUCOSE-60
[**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-13*
POLYS-6 LYMPHS-85 MONOS-9
[**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-198*
POLYS-13 LYMPHS-75 MONOS-12
[**2142-11-19**] 08:02PM LACTATE-2.2*
[**2142-11-19**] 07:35PM cTropnT-<0.01
[**2142-11-19**] 07:35PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.5
MAGNESIUM-1.7
[**2142-11-19**] 07:35PM PHENYTOIN-9.7*
[**2142-11-19**] 07:35PM PLT COUNT-125*
[**2142-11-19**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2142-11-19**] 07:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Mr [**Known firstname **] was admitted as an outside hospital transfer on
dilantin. He was admitted into the ICU on dilantin and was
placed on Keppra as well on [**2142-11-20**]. On [**2142-11-21**] he was tried
off of propfol and was noted to be comatose with shaking of his
left side of his body. He was then placed on Keppra 1500mg [**Hospital1 **]
which was originally placed at 1000mg [**Hospital1 **]. On [**2142-11-22**] He was
tried off of propofol again. He was noted to have frequent
shaking of his left side off of propofol within a 2-3 hour
period. Propofol was again restarted and because he was still
comatose without eeg data we clinically believed he was in
status epilepticus and a loading dose of phenobarbital was
given. His post load dose was 25. Afterward we had some analyzed
EEG data that did not show generalized seizures so phenobarbital
was not continued and propofol was taken off. He continued off
of propofol for the next couple of days and kepra was reduced to
1g [**Hospital1 **]. His Dilantin was titrated to a dose of 300mg Twice daily
and this was titrated to an adequate free dilantin level. on
[**2142-11-25**] Mr [**Known firstname **] was still not able to awaken from his
comatose and further imaging and repeat lumbar puncture were
unrevealing. He respiratory status stablized in the ICU and he
was extubate and remained stable but with poor mental status.
He was transferred to the neurology floor on [**11-30**] and then
began having worsening respiratory distress and breakthrough
seizures. His family decided to make him comfort measures only
and the palliative care team was consulted. He was treated with
morphine for comfort and he expired on [**12-1**].
Medications on Admission:
- ASA 81
- Keppra 1000 [**Hospital1 **]
- Proscar 5
- toprol 50
- zocor 80
- lisinopril 30
- trazodone 50
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4785
} | Medical Text: Admission Date: [**2132-11-26**] Discharge Date: [**2132-12-11**]
Date of Birth: [**2087-12-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Severe Necrotizing Pancreatitis
Pancreatic Retroperitoneal Abscesses
Post-op Anemia
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Drainage of Pancreatic Pseudocysts
Placement of Jejunostomy Tube
History of Present Illness:
This is a 44 year old male admitted with fevers, increased INR
and malaise to [**Hospital 8641**] Hospital on [**2132-11-25**]. He was initially
admitted in [**6-29**] with severe pancreatitis and was transfered to
[**Hospital1 2025**]. He was treated for 1 month for severe necrotizing
pancreatitis. A CT at the time showed multiple pancreatic
pseudocyst. On [**2132-10-10**] he underwent an exploratory laparotomy,
LOA, excision of pancreatic pseudocyst, US guided pseudocyst
aspiration x 2. He had an unremarkable course. Approximately 10
days ago, he developed malaise, fevers and was admitted on
[**2132-11-25**] with fevers to 101. A CT showed multiple retroperitoneal
abscesses and inflammation over the transverse colon.
Additionally, the patient was on Coumadin for a previous DVT and
had an INR of 8.8 on admission.
He reports fever over the last several weeks and also abdominal
soreness. He has had intermittent N/V, decreased PO intake (pain
was worse with food), diarrhea x 3days. He denies HA, CP, SOB,
change in bladder function.
Past Medical History:
Hyperlipidimia
Pancreatitis
Colon Polyps
anemia
HTN
Obesity
Social History:
Nonsmoker
Physical Exam:
99.7, 93, 120/64, 18, 935 RA
Gen: NAD
HEENT: PERRL, EOMI, oralpharynx clear
CV: RRR
Chest: slightly decreased at base RLL
Abd: soft, slightly distended, TTP to epigastric and LUQ
Ext: warm, +2 DP/PT
Pertinent Results:
[**2132-11-27**] 01:48AM BLOOD WBC-5.2 RBC-3.53* Hgb-9.9* Hct-29.4*
MCV-83 MCH-28.1 MCHC-33.8 RDW-15.1 Plt Ct-335
[**2132-11-27**] 01:48AM BLOOD Glucose-104 UreaN-4* Creat-0.6 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
[**2132-11-28**] 03:03AM BLOOD Glucose-137* UreaN-3* Creat-0.4* Na-137
K-3.5 Cl-102 HCO3-27 AnGap-12
[**2132-11-27**] 01:48AM BLOOD ALT-11 AST-13 AlkPhos-119* Amylase-92
TotBili-0.5
[**2132-11-27**] 01:48AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.0 Mg-2.1
CHEST (PA & LAT) [**2132-11-27**] 3:39 PM
INDICATION: Pancreatic pseudocyst. Fever.
IMPRESSION:
1. Bilateral pleural effusions, small on the right, and
small-to-moderate on the left. The left effusion may have a
subpulmonic component.
2. Patchy left basilar opacity, likely atelectasis, although
early focus of pneumonia is not excluded.
3. Possible ascites.
[**2132-12-7**] 06:15AM BLOOD WBC-4.3 RBC-3.08* Hgb-9.2* Hct-26.3*
MCV-85 MCH-29.7 MCHC-34.8 RDW-15.4 Plt Ct-234
[**2132-12-10**] 06:58AM BLOOD Glucose-98 UreaN-19 Creat-0.6 Na-138
K-3.8 Cl-101 HCO3-30 AnGap-11
[**2132-12-7**] 06:15AM BLOOD Amylase-14
[**2132-11-28**] 03:22PM BLOOD ALT-13 AST-19 AlkPhos-90 Amylase-58
TotBili-1.2
[**2132-12-10**] 06:58AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
[**2132-12-9**] 10:20AM BLOOD calTIBC-248* TRF-191*
CT ABDOMEN W/O CONTRAST [**2132-12-8**] 9:40 AM
[**Hospital 93**] MEDICAL CONDITION:
44 year old man s/p pancreatic abscess resection
REASON FOR THIS EXAMINATION:
*PLEASE NO IV CONTRAST* please eval the pancreatic bed for
undrained collection.
CONTRAINDICATIONS for IV CONTRAST: anaphylaxis
HISTORY: 44-year-old man status post pancreatic abscess
resection. Evaluate for undrained collections.
IMPRESSION: Near complete resolution of the pancreatic
collection. Three well positioned drainage catheters. The only
residual small amounts of fluid are in direct contiguity with
the drainage catheters.
[**2132-11-28**] 1:16 pm SWAB R. RETRO PERITONEAL ABSCESS.
**FINAL REPORT [**2132-12-2**]**
GRAM STAIN (Final [**2132-11-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2132-12-1**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2132-12-2**]):
PRESUMPTIVE CLOSTRIDIUM PERFRINGENS. RARE GROWTH
[**2132-11-28**] 12:40 pm TISSUE DEAD PANCREAS.
GRAM STAIN (Final [**2132-11-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] 1649 ON [**2132-11-28**].
TISSUE (Final [**2132-12-1**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
PRESUMPTIVE STREPTOCOCCUS BOVIS. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2132-12-2**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED
[**2132-11-28**] 6:46 pm MRSA SCREEN Site: RECTAL
Source: Rectal swab.
**FINAL REPORT [**2132-12-2**]**
MRSA SCREEN (Final [**2132-12-2**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2132-12-5**] 9:20 am PERITONEAL FLUID JP #1.
GRAM STAIN (Final [**2132-12-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2132-12-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2132-12-11**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
He was admitted on [**2131-11-27**] and was NPO with IVF. A review of his
CT from the OSH revealed multiple retroperitoneal abcesses from
his Necrotizing pancreatitis. There was no way that these would
resolve without surgery.
Pre-operatively he was on Imipenem and Fluconazole. He was
hemodynamically stable and had a fever to 102.6.
He went to the OR on [**2131-11-29**].
In OR, he received 2000ml crystalloid, 2U pRBCs, 3U FFP, drained
approx 1 L purulent material from abscesses. Post-operatively,
he went to the ICU. He remained intubated for 5 days post-op. He
was transferred to the floor on POD 6.
Pulmonary Edema: He remained intubated post-operatively. His
lungs were coarse. CXR ([**2132-11-28**]): Effusion, perihilar edema
suggesting some failure CXR ([**11-29**]): B/l layering eff R>L,
worsening pulm edema CXR x2 ([**11-30**]): Minimal improvement in pulm
edema. CXR ([**12-2**]): slight improvement in b/l pleural effusions.
He was extubated POD 5 and tolerated extubation.
CV: On POD 2, he had symptomatic post-op A-fib with a reate to
150's and a SBP to 88. He received Lopressor IV and converted
back to NSR. He continued on Lopressor for rate control.
GI: He had a NGT to medium suction. The J tube was to gravity.
He was ordered for Octreotide. He abdomen was soft and
nondistended. KUB ([**12-1**]): No dilated loops of small bowel are
seen.
Abd: He has 4 JP drains in place and a feeding J-tube. He had a
midline abdominal incision.
POD 10, he had 2 of his drains removed. The other 2 drains will
remain in place. The staples will remain in place until
follow-up.
ID: He continued on Meropenum, Fluconazole and Flagyl was added.
Antibiotics were D/C'd on POD 10.
Pain: After extubation, he was on a PCA for pain control. He was
eventually transitioned to PO meds and had good control.
Heme: He had moderate anemia post-op. This was followed closely.
His HCT on POD 3 was 23.9, he received 2 Uints of PRBC. His INR
was also elevated and began to drift down. His Coumadin was not
restarted.
Renal: He received a 1 liter bolus x 2 for post-op low urine
output (Oliguria/hypovolemia). The urine output improved as he
began to auto-diuresis. He was then started on Lasix and Diamox
for diuresis and peripheral edema. He had good response to these
medications. His weight decreased and the last Lasix was on POD
11.
FEN: He was started on J-tube feedings on POD. He was advanced
to goal. He was then started on a PO diet on POD 10 and advanced
to a regular diet. His tube feedings were cycled at night. TPN
was also started and continued for 9 days post-op. He will
continue with Tube feedings until follow-up.
Depression: Psych was consulted for depression. He did not want
to start any medications at this time.
Micro: [**12-2**] MRSA screen+; [**11-28**] OR tissueCx GPbact +Strep v.,
Ucx(-), Bld cx pending; [**11-27**] BCx:p UCx
[**11-28**] OR fluid - strep viridans, Strep bovis
[**11-28**] Or tissue: strep viridans (sparse), gram(+) bacteria
(sparse)
Medications on Admission:
tricor 145', nexium 40', lopressor 25''', Creon-20 2 tabs''',
coumadin 5', abl prn, colace prn
Discharge Medications:
1. Tube Feeding
Replete with Fiber 3/4 strength.
Rate 150cc/hr.
Cycle for 14 hours at night.
Flush tubing before and after infusion.
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Severe necrotizing pancreatitis with multiple retroperitoneal
abscesses.
Post-op Anemia
Pulmonary Effusion
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Continue to ambulate several times per day.
.
You will go home with 2 drains in place. Continue with drain
care as instructed by your nurse.
.
Continue tube feedings at night. Continue with J-tube care.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2132-12-22**]. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment. You will need a CT prior to
your appointment. PO contrast only. The secretary will help you
set this up.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2132-12-22**]
11:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2132-12-22**] 10:00
Completed by:[**2132-12-11**]
ICD9 Codes: 5185, 5119, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4786
} | Medical Text: Admission Date: [**2132-11-7**] Discharge Date: [**2132-11-12**]
Date of Birth: [**2061-12-9**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70-year old gentleman with a history of diabetes, chronic kidney
disease (baseline Cr 1.4) and diastolic CHF (EF LVEF>55)
originally presenting from rehab facility on [**11-7**] for one day
of hypotension 3 days after slipping and falling. Per report had
been getting twice his usual dose of valsartan for unclear
reasons. No chest pain, not SOB, but sweaty and mildly
nauseated.
Review of systems on admission was notable for malaise since his
admission for chest pain at the start of [**Month (only) 359**]. He feels
generally weak and apathetic, which is unusual for him. He has
also had a non-productive cough for several weeks, for which he
was started on azithromycin five days ago. He has recently been
constipated. He denies recent fevers, chills, difficulty
urinating or headaches.
In the emergency department his VS were T 98, BP 94/48 improving
to 134/99, HR 60, RR 18 and 100% on RA. He was found to have a
new leukocytosis and crackles on lung exam and was given vanc,
zosyn and flagyl for a hospital-acquired pneumonia. A right IJ
was placed and he was given 3.5L of normal saline with
improvement of BPs. He had elevated LFTs and an abdominal and
pelvic CT scan was done, revealing a moderate pericardial
effusion. He was admitted to the ICU for suspected sepsis.
Past Medical History:
Type 2 diabetes mellitus - diagnosed in [**2121**]
CKD Stage III
Anemia of CKD
Hypertension
Pontine CVA w/ residual left leg weakness
Chronic bronchitis
OSA
COPD
Obesity
Hyperlipidemia
Gout
BPH
H/o BCC
S/p R shoulder replacement
Social History:
He is a retired teacher. He does not smoke or drink alcohol
currently but used both remotely in [**2083**]. He admits to
occasional marijuana. Prior to his worsening weakness and last
hospitalization on [**2131-10-10**] he lived alone and did his own
shopping/cooking and was independent with ADLs/IADLs. He was
admitted now after having 2-3 weeks of rehab and he had been
home for only 1 day. He has no children and has never been
married but has siblings with whom he keeps in touch with
regularly.
Family History:
Largely Noncontributory. The patient's mother had a type of
sarcoma but he is uncertain of additional details.
Physical Exam:
VS: T 97.9 BP 102/64 HR 91 RR 22 O2sat 96 on room air BS 179
GEN: obese, comfortable, NAD
HEENT: MMM
Neck: JVP flat
Cardiac: irregular irregular no R/G/M
Chest: mild bibasilar crackles, otherwise CTAB
Abdomen: soft, NT, ND, NABS
Extremities: 1+ bilateral nonpitting edema
Neuro: AXx3, CNII-XII grossly intact, EOMI
Skin: diaphoretic
Pertinent Results:
Labs on Admission:
[**2132-11-7**] 05:45PM BLOOD WBC-17.2* RBC-4.58* Hgb-13.7* Hct-40.8
MCV-89 MCH-30.0 MCHC-33.7 RDW-15.3 Plt Ct-301
[**2132-11-7**] 05:45PM BLOOD Neuts-88.4* Lymphs-6.0* Monos-4.6 Eos-0.7
Baso-0.4
[**2132-11-7**] 05:45PM BLOOD Glucose-175* UreaN-37* Creat-2.6*# Na-134
K-3.8 Cl-90* HCO3-31 AnGap-17
[**2132-11-7**] 05:45PM BLOOD ALT-85* AST-64* CK(CPK)-53 AlkPhos-352*
TotBili-0.9
[**2132-11-7**] 05:45PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3
[**2132-11-7**] 06:14PM BLOOD Glucose-174* Lactate-1.8 Na-134* K-3.1*
Cl-87* calHCO3-33*
[**2132-11-7**] 06:14PM BLOOD freeCa-1.02*
Labs on Discharge:
[**2132-11-12**] 04:50AM BLOOD WBC-13.9* RBC-4.02* Hgb-12.0* Hct-35.8*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.6* Plt Ct-417
[**2132-11-8**] 03:32AM BLOOD Neuts-85.7* Lymphs-7.9* Monos-5.3 Eos-0.8
Baso-0.3
[**2132-11-12**] 04:50AM BLOOD Glucose-73 UreaN-34* Creat-1.6* Na-141
K-3.7 Cl-99 HCO3-30 AnGap-16
[**2132-11-9**] 01:38AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.7*
Imaging:
LIVER OR GALLBLADDER US [**2132-11-7**]:
1. Gallbladder sludge without secondary findings to suggest
acute
cholecystitis.
2. Diffusely echogenic liver consistent with fatty infiltration.
Other forms of liver disease and more advanced liver diseases
including significant hepatic fibrosis/cirrhosis cannot be
excluded in this examination. Hypoechoic focus adjacent to the
gallbladder fossa most likely represents focal sparing.
CT PELVIS W/O CONTRAST Study Date of [**2132-11-7**]:
1. Moderate sized pericardial effusion, which is larger compared
to [**2132-10-22**].
2. Small bilateral pleural effusions, with opacification of the
right lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis or consolidation.
3. Diverticulosis, without evidence of diverticulitis.
4. Single locule of air within the anterior subcutaneous fat in
the lower
abdomen. This may relate to subcutaneous injection. Clinical
correlation
suggested.
CHEST (PORTABLE AP) Study Date of [**2132-11-9**]:
Comparison is made with prior study [**11-8**]. Enlarged
cardiomediastinal
silhouette is stable. Patient has known pericardial effusion and
mild
cardiomegaly. Minimal bibasilar atelectases larger on the right
side are
unchanged. There is no pneumothorax or enlarging pleural
effusions. Right IJ catheter remains in place.
IMPRESSION: Stable appearance of the chest.
Brief Hospital Course:
Hypotension likely related to the recent increase in his
valsartan. There was some concern that he might have an
increasing pericardial effusion based on his chest CT. An
echocardiogram showed no evidence of tamponade. Observed in MICU
for 24 hours and pressures rising and stable. Transferred to
floor for further monitoring.
1. Hypotension: Resolved with IVF. Given response to fluids most
likely due to doubling of dose of [**Last Name (un) **] and possibly some volume
depletion and not sepsis. Only SIRS criteria was leukocytosis.
Initial concern for tamponade but no evidence of evolving
effusion on echo. Valsartan dose decreased to 40mg Daily from
80mg [**Hospital1 **]. Lasix dose decreased from 80mg Daily from [**Hospital1 **].
2. Acute on chronic renal failure: The patient's Cr is now
resolving to 1.7 from a peak of 2.6 vs a baseline of ~ 1.4. Most
likely cause is pre-renal exacerbated by high levels of [**Last Name (un) **] and
hypotension.
3. Leukocytosis: Improving. 17.2 on admission --> 13.9 day
discharge. UA negative. No clinical symptoms of pneumonia and
CXR suggests atelactasis. Afebrile throughout admission.
Cultures negative on discharge.
4. Pericardial Effusion: New pericardial effusion on CT scan not
present three weeks ago but without significant effusion on
echo. No clinical symptoms of tamponade.
5. Atrial fibrillation: Currently in NSR. Patient had newly
diagnosed Afib on his last admission ~ 4 weeks prior to the
current admission. Continue diltiazem and digoxin.
6. INR elevated 3.8 on day of discharge, recommended to hold
coumadin on day of discharged and start decreased coumadin dose
2 mg on [**2132-11-13**].
7. Type 2 diabetes mellitus: Patient has difficult to control
diabetes and is followed at the [**Last Name (un) **]. His most recent A1c was
8.3%. Was on Insulin 100 units TID
8. Diastolic CHF: No sign of acute CHF episode. Continued
outpatient medications.
Decreased Lasix to 80mg Daily from [**Hospital1 **]. Can increase if patient
becomes fluid overloaded. Recommend daily weights and strict
I/O, if becomes positive increase Lasix. Patient will follow up
with cardiology Dr. [**Last Name (STitle) **] in [**1-11**] weeks.
9. Elevated transaminases: Stable from prior admission when
changes consistent with fatty liver were seen on ultrasound.
10. Depression: Patient reports poor mood and satisfaction. TSH
was normal. He was continued on his Effexor and Celexa.
11. Hyperlidemia: Continued rosuvastatin and niacin.
12. GOUT: Continued Allopurinol
13. COPD: continue Advair, albuterol and ipratropium.
14. History of CVA: Continue plavix.
15. OSA: Pt refuses to use CPAP
Medications on Admission:
MEDICATIONS AT HOME (per [**Hospital1 599**]):
- Allopurinol 300mg daily
- Carvedilol 25mg [**Hospital1 **]
- Clopidogrel 75mg daily
- Digoxin 125 mcg QOD, alternating with 250mcg
- Diltiazem SR 360mg daily
- Duloxetine DR 20mg [**Hospital1 **]
- Advair 100-50 1 puff [**Hospital1 **]
- Furosemide 80mg [**Hospital1 **]
- Insulin humalog SS
- Humulin 22 units daily
((- Insulin Regular Hum U-500 120units QAM, 110 units Qnoon,
110units QPM.))
- Duoneb Q6hrs PRN
- Multivitamin 1 tablet daily
- Niacin 500mg SR
- Ranitidine 300mg daily
- Rosuvastatin 40mg daily
- Valsartan 80mg [**Hospital1 **]??
- Warfarin 3.5mg daily
- Acetaminophen 650mg Q6hrs PRN
- Milk of Mag 30mg daily PRN
- Fexofenadine 60mg [**Hospital1 **]
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QHS (once a day (at bedtime)).
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: One
Hundred (100) units Injection TID w/ meals ().
12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: max 4 grams a day.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
15. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Hold for SBp < 100.
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 90.
20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP < 90.
21. Diltzac ER 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day: Hold for SBP < 90, HR
< 60.
22. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Start [**2132-11-13**]. Due to elevated INR 3.8 holding dose [**2132-11-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Hypotension
2. Diastolic Heart Failure
3. Prerenal acute renal failure on CKD
4. Pericardial effusion without tamponade
5. Type 2 diabetes mellitus
6. Atrial fibrillation
7. Gout
Discharge Condition:
Good
Discharge Instructions:
You were admitted for low blood pressure which was felt to be
secondary to blood pressure medication because of this we have
decreased your Valsartan.
We have made changes to your medication - please follow the list
given to rehab.
Follow-up with your primary care doctor and cardiologist.
Call your doctor if you experience dizziness, chest pain,
shortness of breath or any other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Adhere to 2 gm sodium diet.
You are being discharged to [**Hospital 100**] Rehab.
Followup Instructions:
Appointments scheduled:
Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2132-12-23**] 11:30
Schedule an appointment with your cardiologist Dr. [**Last Name (STitle) **] in [**1-11**]
weeks.
Schedule an appointment with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab. Dr. [**First Name (STitle) **] [**Location (un) **] COMMUNITY HEALTH
CENTER [**0-0-**]
Completed by:[**2132-11-12**]
ICD9 Codes: 5849, 5180, 4280, 2749, 4168, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4787
} | Medical Text: Admission Date: [**2197-9-26**] Discharge Date: [**2197-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
transfer from osh for cath
Major Surgical or Invasive Procedure:
Coronary catheterization with balloon angioplasty of right PDA.
Intra-Aortic Balloon Pump placement
History of Present Illness:
Pt is a 75 yof with pmh of dm2, htn, hypothyroid who experienced
acute sob while cooking dinner. Went to [**Hospital 11047**] hospital where
she was noted to have mild htn (sbp 140) and evidence
desaturation (spO2 90%) ECG with STD in inferior pattern.
.
Exam consistent with acute L heart failure (rales, but no
peripheral edema), patient required intubation secondary to
hypotension and desaturation. Once intubated stabilized given
dobutamine for hypotension and bradycardia. Transferred to
[**Hospital1 **] for urgent cath.
.
At cath with spb 96/66, pa 35/15 stat echo in lab without
evidence of tamponade or severe valve disease (1+mr) rpda to,
crossed and ballon dilated with good improvement in flow and
hemodynamics. Iabp placed for hemodynamic support and
transferred to ccu. Of note cath lab produced >2L urine.
Past Medical History:
Diabetes
Hypothyroid
HTN
Social History:
per family, pt high functioning lives alone in a senior center.
Family History:
nc
Physical Exam:
Afebrile, 87/41, 100% on 60%Fio2.
Vent settings: CMV, Fio2 60%, R 16
Gen: Pt intubated.
HEENT: MMM, PERRL, swan in place.
CHEST: CTAB, no crackles
CVR: RRR, nl s1, s2, no r/m/g.
Abdomen: soft, nt, nd
Ext: no edeam bilaterally, no dopplerable pulses.
Groin: no hematoma, no bruit.
Neuro: intubated and sedated.
Pertinent Results:
11.9\27.9\175
139 \ 3.5\ 112\ 18 \ 23 \ 0.7 \ 184.
Ca 7.5, mg. 1.7, phos2.9
OSH: 3mm std II, III, f, 1mm ste avR
Post cat: NSR at 66. TwI v1-v6, axis nl.
.
Cath [**2197-9-26**]:
.
Lcx - TO prox occlusion with RCA collaterals
LMCA - no disease
LAD - 60% prox 80%D1, diffuse 80% before D2 then TO.
RCA - diffuse disease. 40% ostial, 99% at crux with TO of PDA.
Residual <30%.
.
Hemo
PCW 15, RA 10, AO 78, PA 35/15, RV 35/7
CO/CI - 4.8/2.0
.
ABG.
2AM 7.38/34/125/21 on 60%FIO2.
.
ECHO (EF 25%): Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is severe regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is severely depressed. Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg). Resting regional wall motion
abnormalities include severe hypokinesis to akinesis of the
distal [**12-29**] of the left ventricle. No definite left ventricular
thrombus seen but cannot exclude. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures. There is a
restrictive left ventricular filling pattern consistent with
severe diastolic dysfunction.
.
CT chest: IMPRESSION:
1. Bilateral multifocal pulmonary opacities, more consistent
with pneumonia or aspiration than with pulmonary edema.
2. Large bilateral pleural effusions.
3. Three-vessel coronary artery disease as stated in the
provided history. Extensive atherosclerotic disease in other
visualized vessels.
Brief Hospital Course:
BRIEF OVERVIEW: The patient is an 86 yo female with a history of
diabetes who presented with acute shortness of breath to an OSH
where she was intubated and transferred to [**Hospital1 18**] for emergent
catheterization. Catheterization revealed diffuse disease
including an obstructed PCA (RCA) that was ballooned open.
Because the cath was considered high risk and she was thought to
be a potential CABG candidate, no stenting was performed. It
appeared that hemodynamics improved s/p ballooning, though the
patient had been in what appeared to be cardiogenic shock. As a
result, IABP was placed. The patient did well and was diuresed
aggressively. She was extubated the following day after having
the balloon pump removed. She required a short course of BiPAP
just after extubation and improved consistently from there. She
was seen by PT/OT and recommended for a short stay at a rehab
facility. UTI and possible pneumonia (found on CT chest 2 days
after extubation - pt afebrile without leukocytosis) were
treated with a 10 day course of abx.
.
## CAD -
#Ischemia: The patient was noted to have 3 vd on cath. PDA was
totally occluded and was thought to be the culprit vessel. It
was ballooned open with some improvement in hemodynamics, but
with residual 30% stenosis post-balloon. The patient was
started on ASA, Plavix and lipitor 80. BB and ACEI were
initially held as a balloon pump was placed to assist with
afterload reduction. The patient was started on ACEI, nitro,
and BB over the next 24 hours. She did well and the balloon
pump was removed within 24 hours after her cath. Following
balloon pump removal, the pt was extubated. She did well
initially but shortly thereafter her O2 saturations decreased
and she was started on BiPAP, which she tolerated well. The
BiPAP was weaned off after some hours and she did well on NRB
face mask. Over the next 24 hours she moved from mask to NC.
During this time she did not appear to have any specific ST
changes. For this reason, it was not clear that the patient had
a new ischemic event leading to the pulmonary edema or ongoing.
She was evaluated by the CT surgeons for CABG and thought not to
be an appropriate candidate. Some consideration of LAD stenting
was given, but the patient improved dramatically over time and
it was not clear that the decompensation was due to an acute
event. It was felt that the risks of revascularization
outweighed the benefits at this hospitalization. She should be
continued on a full medical management with
ASA/Plavix/Statin/BB/ACEI.
.
#Pump: Echo was done in the cath lab without obvious segmental
wma. EF 25%, severe hypokinesis of distal [**12-29**] LV. PCWP>18. mild
pulm htn, severe diastolic dysfunction with restrictive filling
pattern E/A 1.29. ?new secondary to ischema given 3VD vs
exacerbation heart failure. Throughout the first days of her
hospitalization the pt was on propofol while intubated and her
HR and BP remained low and she was on dobutamine. When her
sedation was lightened, her vitals returned and she was weaned
from pressors and she was started on BB and ACEI for
cardioprotection.
.
#Rhythm: The patient remained in sinus rhythm throughout her
stay.
.
## respiratory - The patient presented from the OSH intubated
for flash pulmonary edema. She was sedated and remained
intubated for the first two days of her hospitalization. At the
time of her catheterization, her right sided pressures were
normal. Thereafter, the right sided pressures were low
following rapid diuresis. She received a small amount of fluids
and her PAP returned to [**Location 213**]. At that point she was
overbreathing the vent, and the settings were pressure support
with minimal PEEP. She was extubated and initially did well.
However, after 1-2 hours she became increasingly SOB. A CXR
showed some pulmonary edema, and ABG showed some decreased
oxygenation. She was put on BiPAP for support and weaned to O2
facemask over some hours. The following day she was put on
nasal cannula and continued to breathe well. A chest CT showed
large effusions bilaterally and infiltrates more c/w PNA than
with fluid overload. The patient did not have a leukocytosis
nor was she febrile, but in light of these imaging findings, she
was started on levofloxacin for 10d course.
.
#Diabetes - well controlled on RISS at this hospitalization.
Restarted on home oral anti-hyperglycemics.
.
#Hypothyoroid - levoxyl 75 at this hospitalization. Pt to
resume home dose when discharged (unclear if home dose is 75 or
88mcg daily.
.
#Heme: The patient developed an acute decrease in her platelets
from the mid-100's to 99 after having had the balloon pump in
and being on heparin for one day. Her anti-PF4 ab came back
negative after 2 days. In the meantime all heprin products were
held. Plts remained stable or increased for the rest of her
hospitalization.
.
#ID: The patient was found to have a UTI and was started on a
course of cipro. However, when CT [**Location (un) 1131**] showed likely PNA,
she was changed to levofloxacin to address both infections.
250mg q day dosing was used due to the patient's advanced age.
#FEN: Throughout the hospital course, the pt's electrolytes were
repleted to k>4, mg>2.
#Code: remained full code throughout this hospitalization.
#Communication: Son [**Name (NI) 4468**] [**Name (NI) 32570**] is HCP (form was in chart
throughout the hospital stay).
Medications on Admission:
celebrex, levoxyl, glyburide, atenolol.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): For CHF management.
Disp:*30 Tablet(s)* Refills:*2*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: For heart
protection and blood pressure control.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
For heart protection and blood pressure control.
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take as directed for diuresis and to prevent water retention.
Disp:*30 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take as directed for chest discomfort. Repeat if discomfort
persists for >5min. Call your physician after taking this
medication.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day:
Take as you were prior to this hospitalization.
13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn: Please take one tablet if you experience severe
chest pain that is not relieved with rest. IF pain does not go
away repeat in 5 mins and call your cardiologist or [**Last Name (un) 5511**]
emergency room.
Disp:*20 * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Flash Pulmonary Edema
Coronary Artery Disease
Hypotension
CHF
Diabetes
Hypothyroid
HTN
Discharge Condition:
Stable, breathing comfortably, free of pain.
Discharge Instructions:
You were admitted to the hospital because you had difficulty
breathing. For this reason you were intubated. You had a
coronary catheterization, which showed that the vessels in your
heart are narrow. You have congestive heart failure, which
likely led to your difficulty breathing. After diuresis, your
symptoms improved and the breathing tube was removed. You
appear to be doing well now, but there are some important
changes we have made to your medications.
You will need to follow up with your Primary Care Physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 66269**], within the next 2 weeks for further care see appt
below.
You will need to see a cardiologist, as well. You have started
a number of heart medications that will need to be adjusted over
time. You will see Dr. [**Last Name (STitle) 10220**] number appt below.
If you develop chest pain, increasing shortness of breath, groin
or leg pain or bleeding, lightheadedness or dizziness, or if you
lose consciousness or have any other worrisome symptoms, please
seek immediate medical attention.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10220**] ([**Telephone/Fax (1) 4105**]) in [**Hospital 1902**]
clinic on Tuesday [**10-24**] at 9:30AM.
.
Please also follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66269**] on [**10-12**] at 2PM.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Completed by:[**2197-10-3**]
ICD9 Codes: 5990, 486, 2875, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4788
} | Medical Text: Admission Date: [**2133-8-23**] Discharge Date: [**2133-9-1**]
Date of Birth: [**2053-6-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20224**]
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 80-year-old male with PMH significant for asthma,
dementia, likely COPD and gait disorder who was sent to ED by
his nursing home after 2 days of worsening cough and tachypnea.
History limited due to the fact that patient is demented and
speaks Cantonese. History obtained from daughter who is
patient's HCP with help of [**Hospital1 18**] interpreter. Per reports, he
desaturated to the low-mid 80s range on room air earlier in the
night at his nursing home and EMS was called. He was given
albuterol nebulizers en route with improvement to 97-98% O2
saturation on [**9-21**] L NRB en route to [**Hospital1 18**].
On arrival to the ED, his VS were: temp 104.2F, HR 130s, BP
192/98, RR30 and O2 saturation level 100% NRB. In ED, he
received 4L NS IVFs, Combivent nebulizers x 3, Solumedrol 125mg
IV x1, Tylenol 1g x1, and IV Vancomycin and 4.5mg IV Zosyn.
On arrival to the [**Hospital Unit Name 153**], patient appeared to be anxious and
breathing rapid shallow breaths in the high 20s range with O2
saturations in the high 90s on 5L NC. He also displayed
accessory muscle use and had audible wheezes on exam.
ROS: Per patient's daughter he denies headaches, chest pain,
abdominal pain, nausea, diarrhea, dysuria, hematuria. Daughter
states he had one episode of emesis about 3 days ago and he has
had 2-3 days of productive cough. In addition, patient's
daughter denies any history of any known MIs, PEs, CVAs in Mr.
[**Known lastname **].
Past Medical History:
-asthma
-dementia /Alzheimers type
-gait disorder
-dysphagia
Social History:
Cantonese speaking only. Lives in nursing home. Married but wife
lives nearby. Daughter is HCP and also lives nearby. He stopped
smoking 15 years ago after smoking 2PPD x 45 years. No current
ETOH or illicit drug use.
Family History:
Unable to obtain given limited ability to communicate.
Physical Exam:
ON ADMISSION:
Vitals -Temp:96.6F axillary, BP: 110/42 HR: 111 RR: 28 02
sat:99% on 5L NC
GENERAL: patient with pale, sweaty complexion, ill appearing and
breathing rapid shallow breaths with some accessory muscle use
noted
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Dry MM. OP clear/upper dentures.
NECK: No LAD. No JVD. No thyromegaly.
CARDIAC: Rapid but regular rhythm, Normal S1/S2. No murmurs,
rubs or gallops.
LUNGS: Decreased breath sounds at RML and crackles over right
base, poor air movement bilaterally. Some expiratory wheezes
noted bilaterally in mid lung fields.
ABDOMEN: Soft, NT, slightly distended, No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses, pale skin
NEURO: CN 2-12 grossly intact. Preserved sensation throughout.
Moving all extremities but limited strength testing due to
status. Gait assessment deferred
ON DISCHARGE:
Vitals stable
CV: regular, no mrg
PULM: scattered rhonci
ABD: soft, NTND
NEURO: responds to name, non-verbal. No focal deficits
Pertinent Results:
DISCHARGE LABS:
CBC: WBC-15.3* RBC-4.90 Hgb-14.4 Hct-42.6 MCV-87 MCH-29.5
MCHC-33.9 RDW-14.2 Plt Ct-227
CHEM 7: Glucose-155* UreaN-48* Creat-1.7* Na-140 K-3.5 Cl-102
HCO3-24 AnGap-18
Brief Hospital Course:
Mr. [**Known lastname **] is an 80yo male with PMH significant for asthma and
dementia who presents now with imaging, labs and physical exam
findings consistent with acute asthma exacerbation in setting of
a RLL PNA and new sepsis presentation. He had a complicated
medical course and ultimately it was determined to focus on
comfort care given the patient's end-stag dementia and chronic
aspiration. He was discharged to hospice in stable condition.
# Goals of Care: After a long discussion with the family and
the palliative care service, it was determined that the family
would like to focus on comfort given the patient's end-stage
demetia and chronic aspiration. Would recommend morphine prn
for dyspnea or pain with bowel regimen and oxygen or fan as
needed to control respiratory symptoms. Additionally, would
consider scopolamine for control of secretions if clinically
indicated.
# Sepsis/Pneumonia: Patient presented with fevers to 104,
respiratory rate in 30's, and tachycardic to 130s with systolic
blood pressures in the 90's. He was admitted to the ICU and
treated with intravenous antibiotics and improved. He was
transferred to the floor. He had 2 other episodes of acute
respiratory worsening requiring ICU transfer and non-invasive
ventilation. These were thought to be secondary to aspiration
of secretions and food. He completed an 8 day course of
antibiotics for hospital acquired pneumonia after the second
acute worsening. Family meeting and goals of care as above.
# Chronic Aspiration: Likely from demetia though speech/swallow
study was essentially normal. Given that goal of care is
comfort, would allow patient to eat and drink if he wants, but
he does not need to.
# Acute Renal Failure: On presentation, patient's creatinine was
1.4 with a peak of 2.1. Ultimately improved with fluids to 1.7
without further improvement.
# Dementia: End stage, long standing hisotry of Alzhemers.
Goals of care as above. Patient appears somewhat confused and
anxious on exam. Would avoid sedating medications.
# Code Status: DNR/DNI, confirmed with family.
# Contact: Granddaughter [**Name (NI) **]: [**Telephone/Fax (1) 82848**] or [**Telephone/Fax (1) 82849**].
Daughter is at [**Telephone/Fax (1) 82850**].
Medications on Admission:
-Lactulose 30ml qdaily
-MVI qdaily
-Milk of Magnesia -30ml qdaily PRN
-Fleet Enemas PRN
-Robitussin DM -5ml q8h prn cough
-ipratropium/albuterol 0.5/3 mg qid prn wheeze
-trazodone 25mg q6h agitation/insomnia
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Primary:
End-Stage Demetia
Pneumonia
Sepsis
Asthma
Dysphagia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted on [**2133-8-23**] with pneumonia and an infection
in your blood. You were initially treated in the intensive care
unit with IV fluids and antibiotics and you improved.
Because you have end-stage dementia a family meeting was held
and the decision was made to focus on comfort. Therefore your
medication regimen was changed to focus on comfort. The
facility you are going to is the nursing home you've been in.
They will manage your symptoms of shortness of breath or pain
with medications to reduce those symptoms.
Additionally, it was determined that you aspirate your saliva
into your lungs which causes lung damage and shortness of breath
and may cause infection. Unfortunately, there is no way to
prevent this from happening.
You were started on a medication called Clonidine which is a
patch. This is to control your blood pressure because very high
blood pressure and worsen breathing symptoms.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Please follow up with your primary care doctor as needed.
Please keep all of your scheduled appointments.
ICD9 Codes: 0389, 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4789
} | Medical Text: Admission Date: [**2148-1-17**] Discharge Date: [**2148-1-21**]
Date of Birth: [**2073-7-16**] Sex: F
Service: [**Hospital Unit Name 196**]
HISTORY OF THE PRESENT ILLNESS: This is a 74-year-old female
with known coronary artery disease and a positive exercise
treadmill test in [**2147-12-15**] who was transferred from
[**Hospital3 417**] Hospital for a catheterization.
The patient is a 74-year-old female with known CAD, status
post CABG in [**2134**], who reports progressive dyspnea on
exertion and leg weakness over the past year. She originally
attributed her symptoms to being placed on Mevacor. This was
changed to Lipitor but her symptoms have persisted. She
reports lower extremity weakness and dyspnea on exertion when
climbing stairs or walking long distances. She denied chest
pain, palpitations, or syncope. She also reports feeling
more fatigued over the past several months requiring daily
naps.
In [**2147-12-15**], she had an exercise treadmill test which
revealed moderate reversibility in the anterior apical and
lateral walls. A SPECT scan revealed septal hypokinesis and
an EF of 52%. Risk factors include cholesterol, positive
family history. She denied tobacco use, history of high
blood pressure, history of diabetes.
ALLERGIES: The patient is allergic to penicillin and
tetracycline which give her a rash.
MEDICATIONS ON TRANSFER FROM [**Hospital3 **] HOSPITAL:
1. Lipitor 20 mg p.o. q.d.
2. Synthroid 0.2 mg p.o. q.d.
3. Lasix 40 mg p.o. q.d.
4. Potassium 10 mEq p.o. t.i.d.
5. Coumadin 5 mg q.o.d. alternating with 2.5 mg p.o. q.o.d.
6. Heparin drip.
7. Aspirin 81 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Lopressor 25 mg p.o. b.i.d.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Allergic rhinitis.
3. Hemorrhoids.
4. DJD.
5. Anemia.
6. Cataracts.
7. Alopecia.
8. Coronary artery disease, status post CABG with LIMA to
LAD, SVG to D1, SVG Y graft to RCA and OM-1. Catheterization
in [**2140**] showed an occluded SVG to D1. A stress in [**2147-12-15**] showed moderate reversible defect in the anterior
apex and lateral walls with left ventricular dilation.
9. Valvular heart disease, status post aortic valve
replacement and mitral valve replacement in [**2140**],
bioprosthetic valves.
10. Increased cholesterol.
11. Status post left carotid endarterectomy in [**2137**].
PHYSICAL EXAMINATION ON ADMISSION: She was 95% on room air,
blood pressure 119/81, pulse 52, respirations 18. She was
alert and oriented. HEENT examination revealed that the
pupils were 3 mm bilaterally and briskly reactive. The
oropharynx was pink and moist. Cardiovascular: Regular rate
and rhythm. S1, S2. There was a III/VI systolic murmur
along the left sternal border. Respiratory: Clear to
auscultation anteriorly. Abdomen: Soft, positive bowel
sounds. Extremities: Palpable pulses, trace pedal edema.
Right groin site with dressing intact. She had no bruit at
that time.
LABORATORY DATA/OTHER STUDIES FROM THE OUTSIDE HOSPITAL: On
[**2148-1-15**], white count 10.2, hematocrit 39.4,
platelets 200,000. Sodium 135, potassium 3.9, chloride 103,
bicarbonate 27, BUN 21, creatinine 0.8, glucose 74. Lipid
profile: Cholesterol 285, triglycerides 148, HDL 47, LDL
210. LFTs: Total bilirubin 0.4, AST 23, ALT 32, alkaline
phosphatase 90.
The EKG revealed a normal sinus rhythm, PR interval 0.16, QRS
interval 0.12, left bundle branch block.
Catheterization revealed left main coronary artery 90%
proximal lesion, LAD 100% at the origin of the left
circumflex, 40% at the proximal RCA, no new occlusion
proximally, SVG Y graft to RCA and OM patent, LIMA to LAD
patent, two serial 90% stenoses in the aorta proximal to the
iliac bifurcation, 80% stenosis in the right iliac junction.
HOSPITAL COURSE: Essentially, this is a 74-year-old female
with a history of CAD, status post [**Hospital 8466**] transferred to [**Hospital1 **] on
[**2148-1-17**] with increased dyspnea on exertion, leg
weakness over the past year. She had a stress in [**2148-1-14**] which showed reversible defect in the anterior apical
and lateral walls. Her initial catheterization on [**2148-1-17**] revealed a 90% left main coronary artery lesion,
occlusion of the OM-1 limb, a known occluded SVG to D1, and
critical infrarenal aortic disease.
Her peripheral vascular disease prevented intervention to her
CAD at that time. The patient returned to catheterization on
[**2148-1-18**] with successful stenting and PTCA of her
distal aorta, her right common iliac artery, and her left
common iliac artery with normal three vessel runoff to both
feet and widely patent common femoral arteries, external
iliac arteries, and internal iliac arteries, popliteal
arteries, and trifurcation bilaterally.
The patient returned to catheterization on [**2148-1-19**]
for a left main and SVG to OM-1 intervention. During her
intervention to the SVG she suffered a brady systolic arrest.
She had chest compressions for five seconds with transient
15-30 seconds of hypotension with questionable seizure
activity and change in mental status with successful
resuscitation.
She was transferred to the CCU for further monitoring.
Neurology was consulted. The questionable change in mental
status was thought secondary to hypotension versus postictal
state versus an acute bleed secondary to Integrelin.
However, follow-up head CT was negative and her mental status
improved and the initial mental status change was thought
secondary to syncope versus seizure.
The patient spiked a temperature to 102, thought secondary to
aspiration secondary to her decreased mental status. Her
mental status is now improving. Her temperature continues to
remain elevated. She was transferred over the [**Hospital Unit Name 196**] Service
while awaiting a catheterization on [**2148-1-22**] for
intervention to her left main coronary artery 90% lesion.
The patient's temperature continues to trend downward. She
has only a slightly elevated white count at 11 which was
thought secondary to an acute stress response to her recent
asystolic arrest.
At this time, the patient is scheduled to go to
catheterization on the day after this dictation is done.
However, the patient currently is refusing the
catheterization given the pain that she had upon her prior
intervention.
The patient's discharge diagnoses and discharge medications
will be pending in the next dictation summary along with the
remainder of her hospital course.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Name8 (MD) 9633**]
MEDQUIST36
D: [**2148-1-21**] 11:07
T: [**2148-1-21**] 11:53
JOB#: [**Job Number **]
ICD9 Codes: 4111, 4280, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4790
} | Medical Text: Admission Date: [**2172-3-14**] Discharge Date: [**2172-3-30**]
Date of Birth: [**2088-8-10**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Melena, low platelets
Major Surgical or Invasive Procedure:
Blood product transfusions
PICC line placement
History of Present Illness:
Ms. [**Known lastname 90237**] is an 83 y/o F with a h/o critical AS (valve area
of 0.67cm2), AF on coumadin, h/o prior GIB not worked up due to
patient refusal, CRI who was initially transferred from [**Hospital3 12748**] for a CORE valve with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**],
who shortly after arrival was found to have platelets of 6, an
INR of 4.3 and an HCT that was initially 27.3 down to 24.2 with
active melena. She initially presented to [**Hospital3 **] on
[**2172-3-9**] with complaints of tightness and heaviness in her
epigastric region, that lasts for hours and has been present
intermittently for years. During that hospital stay she was
diuresed with an increase in her lasix dose to 80mg from her
home dose of 40mg, and she underwent a work up of her abdominal
pain. She had elevated LFT's, so she underwent a CT and HIDA
scan which showed cholilithiasis, no cholecystitis and
splenomegaly. She was started on a PPI, and transfused 2 units
of PRBC's for her anemia. After her doctors at the OSH felt
that her abdominal pain had resolved she was referred to [**Hospital1 18**]
for a percutaneous aortic valve replacement given her repeated
admissions for heart failure related her critical AS.
.
During her stay at the OSH her platelets were initially 131 on
[**3-9**], then 96 and 86 on [**3-10**], her HCT was 25.5 and increased to
31.6 after 2 units of PRBC's on [**3-10**], after that time she did
not have any further CBC's checked. Her creatinine there was
2.24, which appears to be her baseline and her INR was initally
therapeutic and then increased to 4.0 and remained elevated
despite holding her coumadin.
.
On arrival to [**Hospital1 18**] her initial VS were: 97.8, 156/55, 57, 18,
98% on 2LNC. Initially she had no complaints except that she
felt her abdomen was "tight", but denied any chest pain,
palpitations, shortness of breath, cough, congestion, or
fever/chills. Shortly after her arrival to the floor her
admission labs returned and were notable for platelets of 5, HCT
of 27.3, that on recheck had dropped to 24.2. She was also
noted to be having melanotic stools. A few hours later she
triggered on the floor for bradycardia transiently to the 30's
and relative hypotension to 104/51 from an initial baseline of
156/55. At that time she was started on a PPI gtt, given
500cc's of IVF and 1 unit of PRBC's. At that time given her
multiple medical concerns transfer was initiated to the MICU.
On arrival to the MICU her initial VS were: 97.1, 53, 148/43,
27, 98% on 1.5LNC.
.
On review of systems, she denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Mild CAD
- Mitral valve stenosis s/p balloon valvuloplasty [**2165**] now with
moderate MS and mild MR
- Severe TR
- Atrial fibrillation on Coumadin, currently held
- Vtach with torsades
- ?TIA in the past year
- h/o "arrhythmias"
- CRI
- Gout
- Mild pulmonary HTN
- GIB [**10/2171**], not worked up due to refusal by patient
- Sigmoid diverticulosis
- Pancreatic cyst
- Thalassemia
- Familial Mediterranean ?anemia vs ?macrothrombocytopenia
- h/o anemia
- Hemorrhoids s/p hemorrhoidectomy
Social History:
SOCIAL HISTORY: originally from [**Country 5881**], mainly greek speaking
-Tobacco history: denies
-ETOH: social
-Illicit drugs: denies
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.1 BP=148/43 HR=53 RR=27 O2 sat=98% on 1.5LNC
GENERAL: thin, frail appearing female in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
NECK: Supple with JVP to her earlobes.
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, TTP in the RUQ and epigastric area, +BS
EXTREMITIES: +edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE PHYSICAL EXAM:
O: Tc: 97 BP: 132-155/73-84 HR: 69-82 RR: 18 O2: 97%RA I: 1120
O: 1750
Blood Sugar: 109 <-- 469 <-- 308<-- 176 <-- 139
GEN: NAD, pleasant, frail appearing
HEENT: PERRL, EOMI, MMM
NECK: Visible carotid pulsations, JVD up to earlobe (but has
severe TR)
PULM: bibasilar crackles without wheezes
CARD: RR, 2/6 sem heard at upper sternal borders with radiation
to carotids, III/VI SEM heard loudest at sternal border 5/6th
intercostal space, delayed carotid upstroke,
ABD: Soft, BS+, NT, ND
EXT: 3+ BLE edema, trace edema of upper extremities with
resolving hematomas
SKIN: No rashes
NEURO: Patient oriented x 3, 4/5 strength upper/lower
extremities, CN II-XII intact
Pertinent Results:
ADMISSION LABS:
[**2172-3-14**] 11:45PM BLOOD WBC-7.8 RBC-3.92* Hgb-8.4* Hct-27.3*
MCV-70* MCH-21.4* MCHC-30.7* RDW-21.9* Plt Ct-6*
[**2172-3-15**] 01:16AM BLOOD WBC-6.8 RBC-3.56* Hgb-7.9* Hct-24.2*
MCV-68* MCH-22.1* MCHC-32.6 RDW-22.1* Plt Ct-5*
[**2172-3-15**] 06:19AM BLOOD WBC-7.8 RBC-3.79* Hgb-8.6* Hct-26.4*
MCV-70* MCH-22.8* MCHC-32.7 RDW-22.1* Plt Ct-5*
[**2172-3-14**] 11:45PM BLOOD PT-40.5* PTT-36.8* INR(PT)-4.3*
[**2172-3-15**] 06:19AM BLOOD PT-41.5* PTT-36.4* INR(PT)-4.4*
[**2172-3-15**] 01:03PM BLOOD PT-21.4* PTT-30.7 INR(PT)-2.0*
[**2172-3-14**] 11:45PM BLOOD Glucose-263* UreaN-81* Creat-2.2* Na-135
K-4.5 Cl-100 HCO3-25 AnGap-15
[**2172-3-15**] 06:19AM BLOOD Glucose-60* UreaN-85* Creat-2.2* Na-137
K-4.6 Cl-103 HCO3-27 AnGap-12
[**2172-3-14**] 11:45PM BLOOD LD(LDH)-260* CK(CPK)-10*
[**2172-3-14**] 11:45PM BLOOD CK-MB-3 cTropnT-0.03* proBNP-8183*
[**2172-3-15**] 06:19AM BLOOD CK-MB-3 cTropnT-0.03*
[**2172-3-14**] 11:45PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2172-3-15**] 06:19AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.4 Mg-1.9
.
.
STUDIES:
RUQ U/S [**2172-3-16**]:
IMPRESSION:
1. Shadowing gallstone seen within the gallbladder which does
not appear to be tense or distended. A minimal amount of
gallbladder wall edema is a
nonspecific finding as this may be related to the patient's low
albumin state; however, cholecystitis cannot be ruled out. If
there is concern for
cholecystitis, a HIDA scan could be performed for further
evaluation.
2. Mild splenomegaly.
3. Right pleural effusion
CXR [**2172-3-15**]:
FINDINGS: No previous studies for comparison.
The cardiac silhouette is enlarged. There is also prominence of
the
paratracheal stripe superiorly. This may be due to a prominent
thyroid or
vascular structures, lymphadenopathy or mass is felt less
likely. If there is high clinical concern, this could be further
evaluated with CT. There is coarsening of the bronchovascular
markings without focal consolidation,
pleural effusions or pulmonary edema. Bony structures are
grossly intact.
CXR [**2172-3-18**]:
FINDINGS: In comparison with the study of [**3-17**], there is further
improvement in pulmonary vascular status. Huge enlargement of
the cardiac silhouette persists. Soft tissue prominence in the
right paratracheal region is again seen, consistent with the
known goiter. No evidence of acute focal pneumonia.
Echo [**2172-3-28**]:
The left atrial volume is severely increased. The right atrium
is moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Diastolic function could not be assessed. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is critical aortic valve stenosis (valve area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are severely thickened/deformed. The mitral valve
shows characteristic rheumatic deformity. There is moderate
valvular mitral stenosis (area 1.0-1.5cm2). Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are moderately thickened. There is
a rhematic deformity of the tricuspid valve. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Rheumatic heart disease with moderate mitral
stenosis, critical aortic stenosis, mild to aortic
regurgitation, moderate to severe tricuspid regurgitation and
moderate to severe pulmonary hypertension. Pressure/volume
overload of the right ventricle. Small pericardial effusion
without evidence of volulme overload.
EKG [**2172-3-25**]:
Sinus rhythm with marked first degree atrio-ventricular
conduction delay.
P-R interval at approximately 400 milliseconds. Diffuse
non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2172-3-16**]
cardiac rhythm now appears to be sinus mechanism with marked P-R
interval
prolongation.
Upper Endoscopy [**2172-3-25**]:
Findings: Esophagus:
Lumen: A small size hiatal hernia was seen, displacing the
Z-line to 35 cm from the incisors, with hiatal narrowing at 39
cm from the incisors. Additional findings include erythema and
granularity, consistent with esophagitis.
Stomach:
Mucosa: Diffuse continuous erythema, granularity, friability
and mosaic appearance of the mucosa with contact bleeding were
noted in the whole stomach. These findings are compatible with
gastritis.
Duodenum: Normal duodenum.
Other
findings: No discrete lesion identified on careful inspection.
Impression: Small hiatal hernia
Diffuse gastritis
No discrete lesion
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings account for the symptoms
Change PPI gtt to PPI 40mg [**Hospital1 **]
Treat for H.pylori given positive serology
Continue supportive care with transfusions as needed
.
MICRO:
URINE CULTURE (Final [**2172-3-18**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2172-3-18**]):
POSITIVE BY EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2172-3-23**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
DISCHARGE LABS:
[**2172-3-30**] 05:01AM BLOOD WBC-15.1* RBC-2.93* Hgb-8.4* Hct-25.6*
MCV-88 MCH-28.7 MCHC-32.8 RDW-17.0* Plt Ct-94*
[**2172-3-30**] 05:01AM BLOOD PT-12.7 PTT-24.6 INR(PT)-1.1
[**2172-3-30**] 05:01AM BLOOD Glucose-135* UreaN-114* Creat-1.5* Na-144
K-4.3 Cl-108 HCO3-26 AnGap-14
[**2172-3-29**] 05:07AM BLOOD Glucose-169* UreaN-115* Creat-1.6* Na-142
K-4.5 Cl-109* HCO3-27 AnGap-11
[**2172-3-22**] 04:35AM BLOOD LD(LDH)-241
[**2172-3-21**] 06:22AM BLOOD ALT-21 AST-12 LD(LDH)-258* AlkPhos-105
TotBili-1.3
[**2172-3-29**] 05:07AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.3
[**2172-3-26**] 05:50AM BLOOD Albumin-3.0* Calcium-8.0* Phos-4.0 Mg-2.3
Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname 90237**] is an 83 y/o primarily Greek speaking female with
critical aortic stenosis, h/o mitral stenosis s/p balloon
valvuloplasty 2 years ago, afib, CRI, DM, HTN, MR who initially
presented to an OSH with dyspnea on exertion. She was diuresed
and worked up for chronic abdominal pain, then transferred to
[**Hospital1 18**] for percutaneous aortic valve replacement. She then
developed melena, anemia, thrombocytopenia thought to be
secondary to Idiopathic thrombocytopenia (treated with IVIG,
dexa, now on prednisone), gastritis (H pylori positive treated
with PPI, amox, clarithro). Patient no longer a candidate for
percutaneous valve replacement nor surgical replacement at this
time, peripherally overloaded from blood products and likely
right heart failure - gentle diuresis given preload dependent
state of aortic stenosis.
.
ACTIVE ISSUES:
#) Idiopathic Thrombocytopenic Purpura:
Per OSH records her platelets were 131 on admission, then
decreased to 86 the next day, however no further CBC's were
checked, so the trend over the next five days is unclear. [**Name2 (NI) **]
her report she started having dark stools the day prior to
transfer, her HCT went to 24.2 from 31.6 on [**3-10**]. DIC labs
demonstrated normal fibrinogen & d-dimer, though her coags were
elevated. Her coagulopathy was reversed with IV Vitamin K, and
FFP. Her Platelets continued to be low, and Heme/onc was
consulted. Smear showed rare schistocytes and findings c/w
thalassemia. She was transfused multiple units of platetelets,
though her platelets continued to be low. Heme speculated
post-transfusion purpura versus idiopathic thrombocytopenic
purpura (ITP). Laboratory results were most consistent with ITP
with a positive anti-platelet antibody. She continued to be
intermittently refractory to platelet transfusions. She was
treated with 5 days of IVIG and a dexamethasone taper which was
switched to oral prednisone 60mg daily with good response of her
platelets --> 94 on discharge. The patient was started on
atovaquone 1500mg daily for PCP prophylaxis given prolonged
steroid course.
.
Her hematocrit was also closely followed and she was transfused
PRBCs for Hct less than 24. She did not require any blood
transfusions on the floor. On the day of discharge, she was
hemodynamically stable and Hct was stable. She required total
16 units of PRBC's, 14 bags of platelets, 6 units of FFP, and 2
units of cryoprecipitate over her length of stay.
.
#) Melena:
Patient new melena on history and exam, per her history she had
a recent GI bleed in [**10/2171**] with a work-up deferred by the
patient. She was started on a protonix gtt. GI was consulted.
She underwent upper endoscopy when platelets were above 50 which
showed diffuse gastritis. She was also H. pylori positive.
Treated with amoxicillin, clarithromycin, and pantoprazole. She
had no more N/V and tolerated a regular diet. She was
transitioned to lansoprazole 30mg PO as she had difficulty
swallowing pantoprazole pills. No more melena and stable
hematocrit on the floor.
.
#) Critical aortic stenosis:
The patient has critical aortic stenosis with a valve area of
0.7cm2 on echo done on [**3-28**]. Her volume status was closely
monitored and treated with lasix IV based on her respiratory
status. On discharge, she had bibasilar crackles and JVP to her
earlobe, although she has severe tricuspid regurgitation
complicating this factor. She was saturating well on room air,
94-97%. She will need follow-up with cardiology (Friday [**4-3**]) to further discuss her aortic stenosis. She is currently
not a candidate for percutaneous aortic valve replacement given
her frail status, recent GI bleed, and ITP. She is a very high
risk for surgical valve replacement. On the floor, she was
diuresed with lasix 10-20mg IV to achieve 250-500cc negative
fluid balance.
** Her diuresis will have to be gentle, 250-500cc per day given
her critical aortic stenosis and Preload dependence**
.
#) Atrial fibrillation:
CHADS of 4. Patient with history of afib currently in sinus
rhythm on telemetry. Her coumadin was initially held.
Amiodarone was held in setting of GIB and concern for low BP.
The patient remained in sinus rhythm while on floor. Her
digoxin was restarted at half her home dosing to help with rate
control. The patient was rate controlled without medication
while on the floor, but her digoxin was restarted on the day of
discharge to give her better inotropy as well. After discussion
with GI and Hematology, her coumadin was restarted once her
platelets were consistently above 70. As she is also on
clarithromycin and digoxin, she was started at coumadin 0.5mg
daily. She is at high risk of rebleeding given her ITP and
previous gastritis so this needs to be closely monitored.
.
# Diabetes Mellitus:
Her home glipizide was held. Her blood sugars rose dramatically
in reponse to the dexamethasone and prednisone. She was started
on lantus 20units qHS and a sliding scale. She showed a pattern
of running low blood sugars in the morning (although always
asymptomatic) and high blood sugars (~400) in the evenings. Her
lantus was adjusted to 15units at bedtime then switched to AM
dosing to provide better nighttime control. Her dinner sliding
scale was increased as well to help provide better nighttime
coverage. Goal blood sugars were between 150 to 200 to prevent
hypoglycemia.
.
# CRI:
Had elevated creatinine that was thought to be secondary to poor
forward flow given her critical aortic stenosis. Her fluid
status was carefully monitored and her renal function stablized
at a creatinine of 1.5. Based on outpatient records, her
baseline creatinine seems to be 1.4-1.6.
.
# Urinary retention - Prior to discharge, the patient was noted
to have 600cc of urine in her bladder. She was straight cathed
with good drainage. Anticholinergic medications should be
avoided in this patient. Bladder scans should be done daily on
this patient to evaluate for urinary retention and if she
continues to retain, may need intermittent straight
catheterization or foley placement.
.
# Hypernatremia:
She was noted to be hypernatremic to a peak 157 in the setting
of poor free water intake. Her free water defecit calculated to
be 6 liters and this was supplied gently with careful
monitoring. She was encouraged with free water PO intake and
had stable sodium levels, 144 on the day of discharge.
.
# UTI:
Had a pan-sensitive urinary tract infection while in the ICU,
treated with 3 day course of ceftriaxone.
.
# Gout:
Patient uses Allopurinol prn. No need for current use
.
TRANSITIONAL CARE:
1. CODE: FULL
2. MEDICAL MANAGEMENT:
Prednisone 60mg daily for ITP until Hematology follow up
Blood glucose control on dexamethasone - adjust lantus and
humalog sliding scale as needed
- CARDIOLOGY follow up - Friday, [**4-3**] with Dr. [**Last Name (STitle) **] to
further discuss aortic stenosis and atrial fibrillation
management
- GI follow-up - In [**Month (only) 547**] to discuss severe gastritis - needs to
finish triple therapy, 7 days of therapy (started on [**2172-3-25**])
- GENTLE diuresis to help remove lower extremity edema - lasix
10-20mg IV daily, goal 250-500cc negative daily
Medications on Admission:
- Digoxin 125mg qod
- Amiodarone 400mg daily
- Lasix 40mg daily
- Potassium Cl ER 20mg daily
- Pepcid 20mg daily
- Coumadin 1mg qhs
- Nitro 2% ointment 1 inch strip (30mg) [**Hospital1 **]
- Glipizide 2.5mg daily
- Allopurinol 300mg daily as needed for gout flare
Discharge Medications:
1. captopril 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day). Tablet(s)
2. amoxicillin 250 mg/5 mL Suspension for Reconstitution [**Hospital1 **]:
Ten (10) mL PO Q12H (every 12 hours) for 2 days.
3. clarithromycin 250 mg/5 mL Suspension for Reconstitution [**Hospital1 **]:
Five (5) mL PO BID (2 times a day) for 2 days.
4. atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mL PO DAILY
(Daily): Take with food.
5. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
7. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fifteen (15) units
Subcutaneous qAM.
8. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: Per attached sliding scale
Subcutaneous four times a day.
9. prednisone 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO once a day:
Will be adjusted by Hematologist - Appointment on [**4-1**].
10. digoxin 125 mcg Tablet [**Month/Year (2) **]: 0.5 Tablet PO every other day.
11. Coumadin 1 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Pavilion - [**Location (un) **]
Discharge Diagnosis:
Primary: Idiopathic thrombocytopenic purpura, GI bleed secondary
to gastritis, diabetes mellitus, critical aortic stenosis,
atrial fibrillation
Secondary: Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2172-3-30**]
ICD9 Codes: 5849, 2760, 5990, 4168, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4791
} | Medical Text: Admission Date: [**2136-2-24**] Discharge Date: [**2136-3-12**]
Date of Birth: [**2085-7-19**] Sex: M
Service: MEDICINE
Allergies:
Mezlocillin / Oxacillin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
NGT tube
Temporary dialysis catheter LIJ
Tunnelled dialysis catheter LIJ
History of Present Illness:
This is a 50 year old male with history of hypertension,
osteomyelitis, chronic pain and depression who was brought in
from home after an attempted suicide by narcotic overdose. Per
patient's wife, she heard a thud in the other room and found the
patient "jerking" on the ground. EMS was called and found the
patient to be in cardiac arrest, administered epinephrine with
return of sinus rhythm (no shock given) and subsequently
intubated the patient for airway protection. Patient was found
with an empty bottle of dilaudid. Patient takes methadone and
dilaudid for chronic ankle pain. [**Name (NI) **] wife noted that he
had been very depressed and crying at times over the past few
months.
.
In the ED, vitals 101.8, 110, 75/20, 19, 99%. Toxicology screen
was positive for methadone/opiates and ETOH (level 88),
otherwise negative for aspirin and tylenol. Stat head CT was
negative for bleed or emboli. Chest x-ray showed no acute
infiltrate. EKG showed sinus tach with 1/2mm ST depressions in
V3-V4. Patient's initial lactate 27 and he was given 3 amps of
HCO3 with repeat lactate 10. Patient's initial ABG
6.65/91/348-bicarb 12. Repeat ABG
7.11/44/142/15.
.
Toxicology was consulted. Patient admitted to taking double his
usual methadone dose, but denied ASA, tylenol or other agents.
Toxicology did not fell that patient's presentation was
consistent with narcotic overdose as patient improved without
narcan.
.
Patient was started on Vancomycin, Levofloxacin and Flagyl. He
was bolused 4 liters normal saline. Three PIVs were placed and
Levophed was started peripherally. Patient's SBP increased to
SBO 100s and levaphed was weaned. Patient's levophed stopped
prior to transfer to the MICU.
Past Medical History:
1. chronic pain
2. depression
3. osteomyelitis
4. TR/small ASD
5. HTN
6. microcytic anemia
7. ? OSA
8. pulm nodules-Has abnormal nodules on CXR and CT. ? granulomas
vs. metastatic dz. Had bronch and bx which showed inflammatory
lesions like granulomas around airways. No definite cause. PFTs
normal and patient generally asymptomatic.
9. melanoma s/p resection
Social History:
Patient is married with no children. He works as a speech
pathologist for special children. He drinks 2 beers per night 7
days a week for years, but he and his wife quit 1 month ago.
Patient does not currently use tobacco and quit in college.
Family History:
Parents are alcoholics.
Physical Exam:
VITAL SIGNS: T 101.8 BP 136/81 RR 26 HR 93 O2 sat 97%
VENT: AC 0.6/ 700/ 5/ 26
GENERAL: alert, responding to commands, intubated
HEENT: ncat, epmi, pupils mid size, equal and responsive, neck
supple
CV: RRR 2/6 SM at RUSB
LUNGS: + rhonchi bilat
ABD: +BS, soft, NT, ND
EXT: no c/c/e, + healing scars on RLE
NEURO: MAEW, nonfocal
SKIN: c/d/i- no rash
Pertinent Results:
Labs on admission:
Glucose-162* UreaN-20 Creat-1.3* Na-138 K-2.8* Cl-103 HCO3-19*
AnGap-19 Calcium-5.9* Phos-6.5*# Mg-3.0*
.
WBC-8.1 RBC-5.35 Hgb-17.0 Hct-52.2* MCV-98 MCH-31.8 MCHC-32.6
RDW-12.8 Plt Ct-262
.
Neuts-89.6* Bands-0 Lymphs-7.5* Monos-2.1 Eos-0.7 Baso-0.1
Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL
Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] Ret Aut-1.1*
.
D-Dimer-6501* FDP-40-80
.
ALT-318* AST-1765* LD(LDH)-2396* CK(CPK)-[**Numeric Identifier 7668**]* AlkPhos-51
TotBili-0.4 Lipase-74* GGT-92* Albumin-2.9* UricAcd-15.7*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE
IgM HAV-NEGATIVE Smooth-NEGATIVE [**Doctor First Name **]-NEGATIVE IgG-560* HCV
Ab-NEGATIVE HEPARIN DEPENDENT ANTIBODIES-NEG HERPES SIMPLEX
(HSV) 2, IGG-TEST NEG HERPES SIMPLEX (HSV) 1, IGG-Test NEG
CERULOPLASMIN-Test WNL
.
PT-16.4* PTT-52.8* INR(PT)-1.5* Fibrino-282 Lactate-27.1*
.
[**2136-2-24**] 01:37PM BLOOD CK-MB-4 cTropnT-<0.01
[**2136-2-24**] 05:15PM BLOOD CK-MB-17* MB Indx-0.1 cTropnT-0.02*
[**2136-2-24**] 09:42PM BLOOD CK-MB-20* MB Indx-0.1 cTropnT-0.02*
[**2136-2-25**] 02:00AM BLOOD CK-MB-23* MB Indx-0.0 cTropnT-0.03*
.
Iron-18* calTIBC-215* Hapto-143 TRF-165* Ferritn-595* VitB12-339
Folate-15.9
.
Osmolal-289 TSH-4.2 Cortsol-28.5*
.
BLOOD ASA-NEG Ethanol-88* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
ART pO2-348* pCO2-91* pH-6.65* calHCO3-12* Base XS--31
ART pO2-322* pCO2-70* pH-6.86* calHCO3-14* Base XS--23
-ASSIST/CON Intubat-INTUBATED Comment-VENT 700/2
COHgb-0 MetHgb-1
.
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG RBC-0-2 WBC-[**6-23**]* Bacteri-MANY
Yeast-NONE Epi-0-2 Sperm-FEW
.
URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG
amphetm-NEG mthdone-POS
.
[**2136-2-25**] 04:12AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.010
Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR RBC-0-2 WBC-0-2
Bacteri-MOD Yeast-NONE Epi-0-2 AmorphX-MANY Myoglob-PRESUMPTIV
.
CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-44 Monos-56
TotProt-51* Glucose-105
.
[**2136-3-8**] CATHETER TIP-IV WOUND CULTURE-NO GROWTH
[**2136-3-1**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-NONREACTIVE
[**2136-2-27**] MRSA SCREEN MRSA SCREEN-NEGATIVE
[**2136-2-27**] EBV IgG/IgM/EBNA Antibody Panel [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS
VCA-IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-POSTIIVE;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB-NEGATIVE
[**2136-2-27**] CMV Antibodies CMV IgG ANTIBODY-NEGATIVE; CMV IgM
ANTIBODY-NEGATIVE
[**2136-2-27**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-NEGATIVE
[**2136-2-27**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-NEGATIVE
[**2136-2-27**] MRSA SCREEN MRSA SCREEN-NEGATIVE
[**2136-2-25**] SPUTUM GRAM STAIN-OROPHARYNGEAL FLORA; RESPIRATORY
CULTURE-FINAL OROPHARYNGEAL FLORA
[**2136-2-25**] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC
BOTTLE-no growth
[**2136-2-25**] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC
BOTTLE-no growth
[**2136-2-25**] URINE URINE CULTURE-no growth
[**2136-2-24**] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID
CULTURE-no growth
[**2136-2-24**] URINE URINE CULTURE-no growth
[**2136-2-24**] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC
BOTTLE-no growth
[**2136-2-24**] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC
BOTTLE-no growth
.
.
STUDIES:
Head CT: [**2136-2-24**]:
no acute intracran process extensive fluid in nasal cavity, post
nasopharynx and R sph sinus, likely rel to supine position and
intubation pre-exist mild sinus inflamm chgs
.
C-spine CT:[**2136-2-24**]
no acute fx/alignmt abnlty, poss old compr'n, sup endplate C6,
[**Last Name (un) **] chgs C5/6, w/mod L nf narrowing, ET/NGTs
.
CXR: [**2136-2-24**]
no acute CP procedd, NGT and ETT in appropriate position
.
EKG [**2136-2-24**]
Sinus tachycardia
Possible left atrial abnormality
Incomplete right bundle branch block
Poor R wave progression - probably a normal variant but consider
old
anteroseptal infarct
No change from previous
Intervals Axes
Rate PR QRS QT/QTc P QRS T
117 168 114 300/[**Telephone/Fax (2) 7669**] 6
.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
FINDINGS: BRAIN MRI:
IMPRESSION: Signal abnormalities at both posterior frontal and
parietal convexity region on FLAIR and T2-weighted images
without corresponding enhancement or diffusion abnormalities.
These findings could be secondary to previous infarcts. No
enhancing lesions are seen. If the patient has prior MRI
examinations, comparison would be helpful. The appearances are
not typical for reversible encephalopathy. Small areas of
microhemorrhages are seen in both cerebral hemispheres near the
convexity indicating old hemorrhages. No enhancing lesions are
seen.
MRA OF THE HEAD: Normal MRA OF THE HEAD:
MRV OF THE HEAD: Normal MRV of the head.
.
DUPLEX LIVER OR GALLBLADDER US [**2-25**]:
1. Normal Doppler study.
2. Extrahepatic biliary ductal dilatation with mild intrahepatic
biliary ductal dilatation. An MRCP would be helpful in order to
assess for any obstructive process.
3. Marked wall thickening of the gallbladder with intramural
edema. This can be seen in several clinical scenarios, including
cholecystitis but other features of cholecystitis are not
present such as stones and distention. If however this diagnosis
is strongly suspected clinically a HIDA scan could be performed.
The appearance can be seen in acute hepatic disease and
hypoalbuminemia as well.
4. Possible edema around the head of the pancreas. Correlation
with pancreatitic enzymes to exclude coincident pancreatitis is
recommended.
.
EEG [**2-25**]:
BACKGROUND: Consisted of a 10 Hz posterior predominant rhythm
bilaterally. At times, faster beta rhythms were observed. This
may be
due to medications.
HYPERVENTILATION: Could not be performed as the patient could
not
comply.
INTERMITTENT PHOTIC STIMULATION: Could not be done as this was a
portable EEG.
SLEEP: The patient progressed from wakefulness into drowsiness
but no
stage II sleep was seen.
CARDIAC MONITOR: Showed a generally regular rate and rhythm with
a rate
of approximately 70 bpm.
IMPRESSION: This is a normal EEG in the awake and drowsy states.
No
focal or epileptiform features were observed.
.
ECHO [**2-25**]: The left atrium is mildly dilated. The right atrium
is moderately dilated. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is normal. The ascending aorta is moderately dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2135-5-4**], there is less tricuspid regurgitation,
pulmonary pressures are lower
.
MRI ABDOMEN W/O CONTRAST [**2136-2-26**]:
1. Underdistended gallbladder with no apparent stones.
Gallbladder wall edema/pericholecystic fluid is not a specific
finding. If clinical concern exists for chronic cholecystitis, a
HIDA scan would be the study of choice.
2. Prominent extrahepatic bile duct tapers normally and
demonstrates no evidence of choledocholithiasis.
3. Extensive subcutaneous edema.
4. Bilateral small-to-moderate pleural effusions.
Of note, technical issues prevented complete normal study and no
gadolinium was administered.
.
CHEST (PA & LAT) [**2136-2-28**]: PA and lateral radiographs of the
chest are reviewed, and compared with the previous study of
[**2136-2-25**].
The patient has been extubated. The previously identified
congestive heart failure has been improving. There is continued
cardiomegaly and small right pleural effusion associated with
bilateral lower lobe patchy atelectasis.
Note is made of a question of nodular opacity in the right apex,
which can be composite shadow. When patient is better, evaluate
with repeated PA, bilateral shallow oblique radiographs of the
chest.
IMPRESSION:
1. Improving congestive heart failure with remaining
cardiomegaly and small right pleural effusion.
2. Question of nodular opacity in the right apex.
.
UNILAT UP EXT VEINS US RIGHT [**2136-2-29**]: DVT within one of the
distal right brachial veins as well as cephalic vein. Basilic
vein was not visualized. No evidence of hematoma within the
right upper neck.
.
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2136-3-1**]: Successful
placement of a 14-French 20-cm double-lumen hemodialysis
catheter by way of the left internal jugular vein with tip in
the superior vena cava. The catheter can be used immediately.
.
UNILAT LOWER EXT VEINS RIGHT [**2136-3-2**]: No evidence of DVT in
the right lower extremity.
.
[**Numeric Identifier 7670**] FLUORO 1 HR W/RADIOLOGIST [**2136-3-8**]: Successful conversion
from a temporary left internal jugular to a tunneled
hemodialysis catheter (27 cm from cuff to tip). The catheter is
ready for immediate use.
Brief Hospital Course:
Briefly, this is a 50 year old man with history of hypertension,
depression, chronic pain and osteomyelitis who presented with
likely cardiac arrest secondary to opioid overdose and possible
associated seizure. On admission to the emergency department,
patient was only briefly hypotensive with systolic in 70's which
responded to IV fluid resuscitation and required transient
peripheral levophed. Patient was also empirically started on
broad spectrum antibiotics and given PO charcoal. A LP was
performed to rule out meningitis in setting of witnessed
seizure. Also, of note, patient was in severe lactic acidosis
with pH <7.0 which responded to stat administration of 3 amps of
sodium bicarbonate. Patient's mental status improved after ED
resuscitation and he was transferred to the MICU for further
care.
.
In the MICU, patient subsequently developed elevated LFTs,
rhabdomyolysis and acute renal failure. Patient remained
intubated for airway protection. Initially, patient had a severe
anion gap and non-anion gap metabolic acidosis and respiratory
acidosis. Metabolic acidosis was likely secondary to lactic
acidosis in setting of cardiac arrest decreased organ perfusion
and possible seizure. Etiology of non-gap acidosis was unclear.
Patient's mental status and respiratory acidosis improved and he
was extubated on [**2-26**] after a RSBI ~10. Patient sating 94% on 5L
nasal cannula after extubation. Repeat CXR was improved but
continued to show pulmonary edema. Patient remained stable and
was subsequently transferred to the floor.
.
#. ?Seizure: Patient was initially worked up for seizure with a
differential diagnosis of opiate overdose, vasovagal induced,
infection induced or EtOH withdrawal induced. MRI/MRA/MRV were
negative for emboli or other abnormalities. Repeat ECHO this
admission largely unchanged from prior if not improved. LP was
performed and not consistent with meningitis. Patient with
positive tox screen for alcohol and opiates. Patient admitted to
drinking cough syrup at home. He and his wife had quit drinking
alcohol approximately 1 month ago. Patient was placed on CIWA
scale while on the floor. Unclear whether patient actually
seized or had post cardiac arrest movements however if patient
did seize the likely etiology was either alcohol withdrawal or
opiate overdose induced metabolic derangement. Patient's mental
status returned to baseline and no recurrence of seizures
occurred while in hospital. EEG was negative for seizure.
Nonspecific vascular findings on MRI, per neurology were old and
would not have contributed to current presentation. Plan is to
have patient follow-up with a repeat MRI and see neurology as an
outpatient in [**6-21**] weeks time.
.
#. Rhabdomyolysis: Etiology likely secondary to immobilization
and ischemic compression of muscle induced by opioid overdose
versus drug induced seizures or hyperthermia associated with
excess muscle energy demands. Also, metabolic derangement
including hypokalemia (2.8 on admission) and hypocalcemia (5.9)
may have contributed or caused the rhabdo but unclear etiology
of electrolyte abnormalities ?opioid overdose. CPK peaked at
150,000 on [**2-25**] and then continued to downtrend. Calcium was
repleted aggressively while alkalinizing his urine to prevent
further renal damage.
.
#. ARF: On admission, Cr 1.0 increaed to 4.8 on [**2-26**] and
continued to increase to peak of 10.3 on [**3-1**]. Etiology of acute
renal failure likely secondary to hypovolemia during cardiac
arrest and rhabdomyolysis. Patient was intially aggressively
hydrated and his urine was alkalinized with HCO3 to avoid
further renal damage from myoglobin. He was also given mannitol
to osmotically diurese which was eventually held on [**2-26**]. There
was an unsuccessful RIJ line placement on [**2-29**], no hematoma was
seen on neck US. IR placed temporary dialysis catheter in LIJ on
[**3-1**] and then switched over a tunnelled cath into LIJ on [**3-8**].
Patient initally required daily dialysis and then three times a
week. At time of discharge, patient had gone for 5 days without
dialysis and was making large volumes of urine. Electrolytes
were followed carefully and phosphate binders were used as
needed. He will need to have his electrolytes (Chem 7, calcium,
magnesium, phosphate) checked in 48 hours, 1 week, and two weeks
to ensure recovery of kidney function. He will need removal of
his tunneled hemodialysis catheter in two days, on [**2136-3-14**], to be done by interventional radiology. A renal consult
should be obtained for follow up of chemistries. The renal
consult service will decide when patient will be able to have
his tunneled catheter removed by interventional radiology.
.
#. Chronic pain/R LE pain: Patient with history of right ankle
injury requiring multiple surgeries between [**2126**]-[**2130**]. It was
recommended in [**2130**] that he have his R ankle amputated however
patient decided not to have the amputation and to medically
treat his chronic pain. Had been on methadone and dilaudid PO as
an outpatient. Pain medications were held until patient's mental
status was at baseline and then he was started and gradually
titrated up on a fentanyl patch with oxycodone PRN for
breakthrough. IV diladudid was used as breakthrough which was
subsequently switched to PO dilaudid and then discontinued due
to adequate pain control. Please obtain pain management consult
for pain control if pain is unable to be controlled with
fentanyl patch with oxycodone.
.
#. Depression: Patient now at baseline mental status however
severely depressed. Psychiatry was consulted regarding the
opiate overdose and felt that patient required inpatient
admission for suicide attempt. Continued to hold Zoloft.
Continued 1:1 sitter. As patient was medically stable, he was
transferred to an inpatient psychiatry floor for further care.
.
#. Anemia: Unclear etiology. Hct baseline 29.0. Paitnet received
2 units in hemodialysis on [**3-5**]. Hct remained stable thereafter.
Guaiaced all stools which have been negative.
.
#. R UE brachial DVT: Patient received anti-coagulation for 1
week with IV heparin and then for a short period of time on
coumadin. Review of US with radiology showed distal location of
possible clot and low risk for embolization and so no further
anti-coagulation was planned. Decision not to anticoagulate was
approved by Dr. [**Last Name (STitle) **]. Patient will not need to have heparin SC
injections for DVT prophylaxis if he continues to ambulate.
.
#. Increased LFTs: most likely secondary to acidemia, possibly
shock liver. Initially, RUQ US suggestive for cholecystitis
however subsequent abdominal MRI showed prominent extrahepatic
bile duct tapers normally and demonstrates no evidence of
choledocholithiasis. Liver was consulted and recommended the
following tests: VZV IgG negative, CMV negative, ceruloplasmin
wnl, Hep A, B, C negative, [**Doctor First Name **] and anti-smooth Ab negative, IgG
low, HSV1 IgG-, HSV2 IgG-, EBV IgG+ IgM-. Alkaline phosphatase
and total bilirubin began to downtrend without intervention and
so no HIDA/MRCP was pursued. Near resolution of elevated LFTs at
time of discharge.
.
#. ID: Patient with very high temp in ED. Differential diagnosis
included seizure versus infectious etiology. Patient was
pan-cultured in ED with no growth. Patient was only briefly
hypotensive and on transient levophed. Patient initially
empirically covered with vanco, levo and flagyl. LP negative for
organisms and not consistent with meningitis. On [**2-26**],
antibiotics were discontinued given low suspicion for infection.
.
#. HTN: Continued to hold BP agents and follow SBP closely.
.
#. Obstructive sleep apnea: Unclear whether patient suffers from
this but he can schedule a sleep study as outpatient.
.
#. Abnormal chest x-ray findings: Patient will need to follow-up
with chest x-ray with PA/LAT/bilateral shallow oblique views to
re-evaluated possible nodular opacity in right apex of lung seen
on chest x-ray [**2136-2-28**]. However this admission, no definite
opacity in right apex of lung was seen in subsequent chest
x-rays. Patient has a remote history of pulmonary nodules of
unclear etiology. He would likely benefit from repeat imaging.
.
#. FEN: Patient is no longer requiring dialysis, watch for
electrolyte abnormalities
.
#. PPX: SC heparin, encouarge ambulation, pneumoboots
.
#. Access: Tunneled hemodialysis catheter. Peripheral IVs
.
#. Communication: Wife: [**Telephone/Fax (1) 7671**] (c) and [**Telephone/Fax (1) 7672**] (h)
[**Doctor First Name **]
.
#. Code: Full
.
#. Patient is medically stable to be discharged from the medical
floor for transfer to psychiatry.
Medications on Admission:
1. Aspirin 235mg PO QD
2. Methadone 40mg PO TID
3. HCTZ 25mg QD
4. Lisinopril 10mg QD
5. Zoloft 100mg QD
6. Dilaudid 4mg Q4H:PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as
needed for insomnia.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours.
8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
11. Outpatient Lab Work
Chem 7, calcium, magnesium, phosphate to be checked on:
[**2136-3-14**].
[**2136-3-19**].
[**2136-3-26**].
This should be followed by the renal consult service.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
opiate overdose
alchohol abuse/dependence
cardiac arrest
rhabdomyolysis
acute renal failure
depression NOS
.
Secondary diagnosis:
chronic right ankle pain
history of osteomyelitis
hypertension
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed. Consider restarting blood
pressure medications once renal function improves.
.
Please get repeat chest x-ray (PA/LAT/bilateral shallow oblique
views) to re-evaluated possible nodular opacity in right apex of
lung seen on chest x-ray [**2136-2-28**].
.
Please remember to get a repeat brain MRI as scheduled by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**].
.
If you have any change in mental status, shortness of breath,
chest pain, nausea/vomitting, decreased urine output,
return to the emergency department.
.
If pain is not well controlled on the fentanyl patch with
oxycodone, obtain pain management consult.
.
Patient does not need heparin SC for DVT prophylaxis if he is
able to ambulate.
.
Obtain renal consult for follow up of acute renal failure.
Please have your blood work checked for recovery of your renal
function.
You will need the following labs checked on [**2136-3-14**], [**3-19**], [**2136**], and [**2136-3-26**].
Chem 7, calcium, magnesium, phosphate. This will be followed by
the renal consult service.
.
You will need to have your hemodialysis catheter removed by
interventional radiology. This should happen in [**2-17**] days. The
renal consult service will determine when this happens.
Followup Instructions:
PROVIDER: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **] NP/[**Name6 (MD) **] [**Name8 (MD) **] MD
DATE/TIME: [**2136-3-26**] 1:20pm
LOCATIONS: [**Hospital Ward Name 23**] Clinical Center [**Location (un) 895**]
PHONE: [**Telephone/Fax (1) 250**]
.
PROVIDER: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD (NEUROLOGY)
DATE/TIME: [**2136-4-17**] 8:00am
LOCATION: [**Hospital Ward Name 23**] Clinical Center [**Location (un) 861**]
PHONE: [**Telephone/Fax (1) 541**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. (CARDIOLOGY) Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2136-4-10**] 3:15
.
Please follow-up in [**Hospital 2793**] clinic by calling [**Telephone/Fax (1) 60**] and
scheduling an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7674**].
.
ICD9 Codes: 5849, 2762, 4019, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4792
} | Medical Text: Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old Cantonese speaking male with history of
thoracic aortic aneurysm who presents s/p recent admission to
[**Hospital1 336**] for mechanical fall, now with respiratory failure.
According to the family and EMS notes, the patient has had
increasing respiratory difficulties and had CXR yesterday wihich
showed RLL infiltrate. Was stable until this a.m. when he
developed acute OB approximately 1 hour after eating. O2 sat was
75-81% on NRB, received nebs, 200cc bolus for BP 90/54. +
chronic cough but no fevers or chills. Transferred to [**Hospital1 18**] for
further management.
.
In the ED the patient was tachypneic to 120 and hypoxic with O2
85% on NRB and decision was made to intubate (BP 105/59) - given
succinylcholine, versed, vecuronium. Was hypertensive
transiently to 209/114 but decreased with sedation. CXR with RLL
infiltrate and widened mediastinum and patient given CTX,
vancomycin, flagyl x 1 (family did not want CTA to eval for abd
aortic aneurysm). Also given decadron 10mg IV x 1 for history of
COPD.
.
Of note, patient recently admitted to OSH (NEMIC?) on
[**11-18**] with mechanical fall c/b transverse fracture through
C7 spinous process and BL laminar fracture of T1 vert. body,
both felt to be old based on MRI and spine cleared. Also with
aortic aneurysm (5x5.3) that family did not want to pursue
further with CTA. Also had high O2 requirement, unclear
etiology, but family stated this was baseline.
Past Medical History:
Dementia - knows person, not place or time, not always
communicative
thoracic aortic aneurysm, diagnosed incidentally 4 years ago
Muscle atrophy
benign prostatic hypertrophy
recurrent pneumonias
irritable bowel syndrome
Anxiety NOS
Aplastic anemia
Subdural hemorrhage - traumatic
Spinous process fx of C7
T1 vert body fx
Fx femur
DJD
Social History:
10 pk yr tobacco, quit 45 yrs ago, from [**Country 16225**], cantonese
speaking, lives with family prior to rehab at [**Location (un) **] Health.
Wife and 8 children live in [**Location (un) 86**] area.
Family History:
noncontributory
Physical Exam:
Vitals: 98.4, 92, 113/62, 28, 93% on AC 400/18/5/0.5 with ABG
7.28/46/90, PIP 21
HEENT: 3-->2, cataract on left, anicteric sclera, MM dry, OP
clear
Neck: supple, no LAD, no thyromegaly, no JVD
Cardiac: RRR, NL S1 and S2, no MRGs
Lungs: faint occ exp wheeze, faint crackle at RL base
Abd: soft, NTND, NABS, no HSM, no rebound or guarding, no
palpable mass
Ext: warm, 2+ DP pulses, no C/C/E
Neuro: responds to painful stimuli, MAE, sedated on versed
Pertinent Results:
EKG [**2152-11-5**]:
sinus tachycardia, LAD, nml intervals, 0.5mm ST depressions in
II, III, aVF, V5, V6, unable to assess precordial leads fully as
V4 missing
.
CXR [**2152-11-5**]:
1. Markedly enlarged contour of the left superior mediastinum.
A chest CT is recommended to evaluate for possible aortic
aneurysm.
2. Patchy opacity involving the right mid and lower lungs could
represent infection or aspiration.
3. Appropriate lines and tubes.
.
CT HEAD OSH:
resolution of Rsubdural, cerebral atrophy, white matter ischemic
changes, lacunar infarcts, menigioma - calicified and stable in
right frontal lobe
Brief Hospital Course:
Mr. [**Known lastname **] is a [**Age over 90 **] year old male with h/o PNA, COPD, aortic
aneursym, who presents with respiratory failure. Based on CXR,
leukocytosis, exam, acute onset respiratory failure was likely
due to aspiration pneumonia. Course is suggestive of frank
aspiration episode given his known h/o aspiration and the acute
onset following a meal. He was initially admitted to the MICU
service intubated from an outside hospital following acute
respiratory failure. He was started empirically on Vancomycin &
Zosyn on admission to our unit. Sputum cultures later grew
coagulase-positive staph aureus, and Vancomycin was continued
until organism was reported as sensitive to oxacillin. He was
then continued on Nafcillin in lieu of Vancomycin. After a few
days without improvement, he becamse hypotensive with good
response to fluid boluses; however, his wife [**Name (NI) 382**] declined
escalation of care, specifically including central access,
bronchoscopy, or pressor support. At this initial family
meeting, she also confirmed that him to be DNR/DNI. Mr. [**Known lastname 70798**]
sons [**Name (NI) **] and [**Name (NI) **] thereafter expressed concern that continued
mechanical ventilation, which was making him visibly
uncomfortable, was not in keeping with his wishes, and he was
extubated. He initially remained on face mask oxygen and
continued antibiotics s/p extubation, despite medical
interpretation of his grim prognosis. Ultimately, however, his
goals of care were transitioned to comfort measures only, and he
was started on a morphine drip and palliative care measures.
Establishment of these goals required repeated meetings with the
sons and extended family members, and ultimately sons [**Name (NI) **]
and [**Name (NI) **] expressed a clear understanding of his condition,
enabling them to arrive at this difficult decision.
Medications on Admission:
Sertraline 25 PO QD
Protonix 40 PO QD
Levothyroxine 25mcg PO QD
Colace 100 PO BID
Senna
MVI
Ferrous sulfate 325 TID
Tylenol prn
MOM, dulcolax, fleets prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration pneumonia
Respiratory failure
Aortic aneurysm
Chronic aspiration
Hypotension
Discharge Condition:
Expired
ICD9 Codes: 5070, 496, 2760, 4589, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4793
} | Medical Text: Admission Date: [**2107-10-24**] Discharge Date: [**2107-11-9**]
Date of Birth: [**2025-11-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13565**]
Chief Complaint:
Falls - found to have R cerebellar hemorrhage at OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 61509**] is a LHM, and is a retired printer (former veteran),
who normally does cross-word puzzles, Sodoku and plays Game Boy.
He was in his usual state of health until 3 am on [**10-24**]. His
step-son, [**Name (NI) **] [**Name (NI) 36913**], whom he lives with, found him sitting
by the front door, drenched in blood, and trying to get out. Mr
[**Name13 (STitle) 36913**] cleaned his step-father up, and noticed that he had hit
the right side of his forehead and right forearm. Mr [**Name13 (STitle) 36913**]
took his father back to bed, at around 4 am. Mr [**Known lastname 61509**] [**Last Name (Titles) **] up
around 6:30 am, and had breakfast around 7 am which consisted of
his usual bowl of cereal and two cups of coffee. Mr [**Known lastname 79898**]
daughter-in-law [**Doctor First Name **] noticed that he had made a mess in the
kitchen earlier that morning, taken the kitchen rug and tried to
wrap the table in it. However, both Mr and Mrs [**Last Name (STitle) 36913**] left for
work, requesting their daughter ([**Name (NI) **]) to look in on Mr
[**Name (NI) 61509**]. [**Doctor First Name **] came by to give Mr [**Known lastname 61509**] lunch, and
found that there was more blood in the house, in addition, he
had vomited his breakfast up on the living room sofa. She
noticed that while he was eating his bowl of soup, his soup
spoon kept missing his mouth. In addition, she noticed that her
grand-father's speech was slurred. [**Doctor First Name **] took her Grand-father
to the [**Hospital3 **] [**Name (NI) **]. He had a CT of his brain which
showed a right cerebellar hemorrhagic lesion with vasogenic
edema and some compression of the fourth ventricle, so he was
transferred to [**Hospital1 18**] ED. At the ED he was reviewed by
Neurosurgery.
Review of systems: Apart from headache, the rest of his systems
review was apparently negative.
Past Medical History:
1. Asthma
2. Osteoporosis
3. Osteoarthritis
4. s/p bilateral catarect surgery
Social History:
Lives with his step-son who is his only child and his HCP, his
name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His
PCP is Dr [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an
ex-smoker, smoking up to two packs per day (not known over the
number of years). Mr [**Known lastname 61509**] does not drink alcohol. His bedroom
is on the [**Location (un) 1773**], and he normally manages his ADLs.
Family History:
Not known
Physical Exam:
Vitals: T99, HR 40, BP 157/60, RR 16, SpO2 96% on room air
General: right forehead and right arm bruises noted.
HEENT: complained that it tickled when trying to examine the
cervical lymph nodes.
Resp: Poor air entry in the right middle zone
CVS: difficult to hear the heart sounds clearly, as he would not
stop talking
GI: Soft, non-tender with normal bowel sounds.
Neurological Examination
Mental status: Awake and alert, multiple promptings for the
exam. Oriented to person, [**Location (un) 86**] and [**2107**]. Normal repetition; no
anomia. Moderate dysarthria. Registers 0/3,recalls 0/3 in 5
minutes. Right-left confusion.
Cranial Nerves: Fundoscopic examination kept closing his eyes
tightly. Pupils equally round and reactive to light, 3 to 2
mmbilaterally. Visual fields appear to be full to confrontation,
but he is easily distractible. Extraocular movements intact
bilaterally with nystagmus to the right. Sensation appears to
beintact V1-V3. Facial movements are symmetric. Palate
elevationsymmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline.
Motor: Decreased bulk diffusely but normal tone bilaterally. No
observed myoclonus, asterixis, or tremor. No pronator drift.
Full strength in all muscles tested.
Sensory testing was totally unreliable.
Reflexes: 2+ and symmetric throughout. Positive Babinski on the
right.
Coordination: Normal finger-nose-finger, heel to shin, and fine
finger movements.
Gait: Unsafe on his feet very unsteady
Pertinent Results:
[**2107-10-24**] 03:55PM BLOOD WBC-8.6 RBC-3.82* Hgb-11.9* Hct-34.0*
MCV-89 MCH-31.2 MCHC-35.1* RDW-13.7 Plt Ct-278
[**2107-10-24**] 03:55PM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-143
K-4.1 Cl-109* HCO3-23 AnGap-15
[**2107-10-25**] 02:43AM BLOOD ALT-11 AST-18 AlkPhos-92 TotBili-1.0
[**2107-10-24**] 03:55PM BLOOD CK-MB-4
[**2107-10-25**] 02:43AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.1
[**2107-10-24**] 03:55PM BLOOD TotProt-6.5
EKG [**10-24**]: Sinus bradycardi. Left bundle branch block
CT head:
1. 1.5 cm hyperdense lesion in the right cerebellar hemisphere,
with
surrounding edema, and mild effacement of the fourth ventricle.
Differential considerations include hyperdense or hemorrhagic
metastasis, versus vascular malformation, or other source of
hemorrhage, including hypertensive bleed. MRI with contrast is
recommended for further evaluation.
2. 1.3 cm probable small calcified meningioma right middle
cranial fossa.
This could also be more definitively characterized by MRI.
3. Vascular calcifications, and bilateral basal ganglia chronic
lacunar
infarcts, and right frontal chronic infarction.
MR head: Approximately 1.5-cm lesion in the right cerebellar
hemisphere
with surrounding edema most consistent with a hemorrhagic tumor.
Adjacent
enhancement in the cerebellar sulci may be leptomeningeal
seeding from a
tumor. These findings are most consistent with a malignant
hemorrhagic tumor.
[**2107-11-8**] 11:20AM BLOOD WBC-22.7* RBC-4.08* Hgb-12.7* Hct-37.4*
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.9 Plt Ct-373
[**2107-11-5**] 07:20AM BLOOD Neuts-94.3* Lymphs-3.9* Monos-1.8* Eos-0
Baso-0
[**2107-11-2**] 09:10AM BLOOD PT-13.0 PTT-28.1 INR(PT)-1.1
[**2107-11-8**] 11:20AM BLOOD Glucose-166* UreaN-38* Creat-1.0 Na-136
K-4.3 Cl-96 HCO3-26 AnGap-18
[**2107-11-5**] 07:20AM BLOOD Glucose-125* UreaN-32* Creat-0.8 Na-139
K-4.2 Cl-100 HCO3-28 AnGap-15
[**2107-11-3**] 06:20AM BLOOD Glucose-107* UreaN-34* Creat-0.8 Na-138
K-4.5 Cl-103 HCO3-24 AnGap-16
[**2107-11-5**] 07:20AM BLOOD ALT-24 AST-17 LD(LDH)-282* AlkPhos-74
Amylase-65 TotBili-0.8
[**2107-11-5**] 07:20AM BLOOD Albumin-3.6 Calcium-9.0 Phos-4.8* Mg-2.4
[**2107-11-5**] 01:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MRI Brain [**10-24**]: FINDINGS: There is a well-defined hyperintense
lesion within the right cerebellar hemisphere, measuring
approximately 15 x 12 mm. T1-weighted imaging shows
inhomogeneous signal with a surrounding dark ring. Gradient-echo
sequence shows the lesion to be hypointense. There is a large
area of surrounding edema. On post-contrast images, there is
uniform enhancement of the dura. There is also enhancement of
the cerebellar sulci which could signify leptomeningeal seeding
from a tumor.
IMPRESSION: Approximately 1.5-cm lesion in the right cerebellar
hemisphere with surrounding edema most consistent with a
hemorrhagic tumor. Adjacent enhancement in the cerebellar sulci
may be leptomeningeal seeding from a tumor. These findings are
most consistent with a malignant hemorrhagic tumor.
MRI Brain [**11-7**]: Prelim read: Large decrease in mass effect of
right cerebellar mass on fourth ventricle since MR [**First Name (Titles) **] [**10-24**]
with small improvement in mass effect seen since head CT of
[**11-4**].
Brief Hospital Course:
Patient is a 81 year old LHM with a h/o smoking presents with
recent multiple falls with possible loss of balance per patient.
He also developed nausea and vomitting plus bifrontal headache.
Patient was found to have 1.5cm R cerebellar hemorrhage with
significant vesogenic edema and some effacement of 4th
ventricle. He was started on Decadron and initially admitted to
ICU where he remained stable with little neurological findings.
Neurosurgery and neuro-oncology were consulted given the high
index of suspicion for either primary CNS or metastatic tumor.
CT of thorax also performed given hx of smoking and possbile
primary etiology being lung, thyroid, GI and renal which was
unremarkable. While in the ICU, patient also had
moderate/severe sundowning. He was given Seroquel as needed.
On HD #3, he was transferred to general service.
On the general service he had a fairly uneventful course. His
major issue initially was significant sun-downing which improved
with a regemin of scheduled seroquel and trazadone. Lately he
has been much improved without significant trouble, although he
does have some confusion worse at night and early morning. He
has had significant improvement in his dysarthria as well. Over
the past week he was noted to have a persistent elevated WBC
count. An exhaustive work-up was done including several
negative blood and urine cultures, chest-xray and lower
extremity dopplers. This leukocytosis is likely due to steroids
and not an acute infection. He has been afebrile throuhgout the
hospital course.
Recently his biopsy results returned as inconclusive. He had a
repeat MRI which showed stable lesion with decreased swelling.
He was discussed at tumor board and it was decided to wean the
steroids and have a follow-up MRI in [**1-12**] months to evaluate
progression. He will follow-up in Brain [**Hospital 341**] Clinic as
scheduled.
It should be noted that he had evidence of a right subdural
hygroma on his initial and follow-up scans, deemed incidental to
his presentation.
His exam upon discharge is significant for oriented to person
and year, often not to place. He is mildly dysarthric. He has
surgical pupils bilateral. EOMI are full with few beats of
nystagmus on right end gaze. Face is symmetric. He has full
strength throuhgout. He has slight asterixis L>R. His right
sided is mildly dysmetric with finger-nose-finger and he has
slight overshoot on rapid actions. He has a steady gait with
assistance.
Medications on Admission:
Fosamax
Advair
Serevent
Albuterol as needed
Discharge Medications:
1. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three
times a day for 2 days: From [**Date range (1) 68310**], take 8mg in the
morning, 6mg in the afternoon, and 8mg at night.
Disp:*qs Tablet(s)* Refills:*0*
2. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three
times a day for 2 days: From [**Date range (1) **], take 8mg in the
morning, 6mg in the afternoon and 6mg at night.
Disp:*qs Tablet(s)* Refills:*0*
3. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three
times a day for 2 days: From [**Date range (1) 79900**], take 6mg three times a
day.
Disp:*qs Tablet(s)* Refills:*0*
4. Dexamethasone 2 mg Tablet Sig: as dir Tablet PO three times a
day for 2 days: From [**Date range (1) 25351**], take 6mg in the morning, 4mg in
the afternoon, and 6mg at night.
Disp:*qs Tablet(s)* Refills:*0*
5. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO three times
a day for 2 days: From 11/6-7, take 6mg in the morning and 4mg
in the afternoon and at night. Tablet(s)
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times
a day for 2 days: From [**Date range (1) 21385**], take 4mg TID.
7. Dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO three times a
day for 2 days: From [**2110-11-20**], take 4mg in the morning, 2mg in
the afternoon, 4mg at night.
8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: Take from [**2112-11-22**].
9. Dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO twice a day for
2 days: Take 4mg in the morning and 2mg at night from [**2014-11-23**].
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: Take from [**2016-11-25**].
11. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 days: Take from [**2018-11-27**].
12. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Take from [**2020-11-29**] then discontinue dexamethasone.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
20. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
21. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
22. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
23. Nystatin 50,000,000 unit Powder Sig: One (1) PO five times
a day: swish and swallow.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Cerebellar hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a cerebellar bleed. Brain
biopsy failed to reveal a diagnosis, which may be tumor or
amyloid angiopathy. You will be sent to rehab and return for
follow-up.
Followup Instructions:
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2107-12-19**] 1:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2107-12-19**]
11:15
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4794
} | Medical Text: Admission Date: [**2106-6-1**] Discharge Date: [**2106-6-8**]
Service: MEDICINE
Allergies:
Depakote
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
fiberoptic nasal intubation
extubation
PICC line replacement
G-tube replacement
History of Present Illness:
Pt is a [**Age over 90 **]F with hx aspiration PNA, g-tube, dementia, who was
BIBEMS after being found in NH in resp distress. In the nursing
home, she was found to be desaturating to high 80's on several
liters NC. Desat to 80's on O2, tachypnea, unresponsive,
fiberoptic nasal intubation
.
In the ED, she was tachypnic and unresponsive. Her vitals were
initially temp101.1 HR112 BP178/87 RR 30 100% NRB. Although she
was DNR/DNI, she was intubated after discussion with her [**Age over 90 802**].
Her SBP dipped to SBP 70 breifly and returned to 101/37 with one
liter.
Her vitals now are temp 93 101/37 14 100% 100x12 PEEP 5. Lactate
1.6. She was given Vanc/Zosyn/Levo. Lactate 1.6.
.
Of note, she was recently discharged from the ICU on [**6-1**] after
sepsis and E.coli PNA [**3-15**] to aspiration PNA. She was treated
for healthcare associated pneumonia with vancomycin, zosyn and
levofloxacin. Her sputum ended up growing ESBL Ecoli so she was
started on meropenam and completed an eight day course.
Past Medical History:
# moderate to severe dementia
# Osteoporosis
# Chronic Diastolic Heart failure
# mild-moderate systolic pulmonary hypertension
# history of depression
# Malnutrition - moderate to severe, likely secondary to
dementia
# atrial fibrillation
# aspiration pneumonia ([**1-18**], with complicated course with
intubation, pressors, VAP, tension pneumothorax from line
insertion, chest tube, thrombocytopenia)
Social History:
- Ms. [**Known lastname 98899**] [**Last Name (Titles) 546**] at [**Hospital1 599**] of [**Location (un) 55**]. She was married
many years ago and never had any children.
FUNCTIONAL STATUS: She at baseline is minimally oriented and
interactive according to staff at [**Hospital1 **]. Prior to her first ICU
admission this fall, she was able to transfer with a two person
assist. Now requires a [**Doctor Last Name 2598**] lift to transfer her.
Family History:
(from chart review) Mother died of old age in her late 90's.
Physical Exam:
Gen: Frail, elderly, intubated, kyphotic
HEENT: PERRL
Heart: s1s2 RRR
Pulm: Rhonchi throughout
Abd: soft, NT/ND
Ext: no c/c/e
Neuro: Sedated
Skin: large decubitus over R buttock, bone visible, no
purulunce, no edema, clean appearing
Pertinent Results:
CBC
[**2106-6-1**] 04:30PM BLOOD WBC-13.1*# RBC-3.40*# Hgb-10.2*#
Hct-32.9*# MCV-97 MCH-29.9 MCHC-31.0 RDW-15.7* Plt Ct-606*#
[**2106-6-3**] 03:03AM BLOOD WBC-7.5 RBC-2.70* Hgb-8.1* Hct-24.4*#
MCV-90# MCH-30.1 MCHC-33.3 RDW-15.5 Plt Ct-303
[**2106-6-4**] 02:51AM BLOOD WBC-5.4 RBC-2.45* Hgb-7.6* Hct-22.6*
MCV-93 MCH-30.9 MCHC-33.4 RDW-15.7* Plt Ct-360
[**2106-6-5**] 04:56AM BLOOD WBC-6.3 RBC-2.61* Hgb-7.9* Hct-24.2*
MCV-93 MCH-30.3 MCHC-32.7 RDW-15.8* Plt Ct-318
[**2106-6-6**] 03:31AM BLOOD WBC-6.2 RBC-2.59* Hgb-7.8* Hct-23.5*
MCV-91 MCH-30.1 MCHC-33.1 RDW-15.4 Plt Ct-361
[**2106-6-7**] 04:15AM BLOOD WBC-7.3 RBC-2.62* Hgb-7.9* Hct-24.1*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.8* Plt Ct-357
.
Chem 7
[**2106-6-1**] 04:30PM BLOOD Glucose-187* UreaN-20 Creat-0.5 Na-139
K-4.6 Cl-99 HCO3-35* AnGap-10
[**2106-6-3**] 03:03AM BLOOD Glucose-106* UreaN-19 Creat-0.4 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2106-6-4**] 02:51AM BLOOD Glucose-102 UreaN-18 Creat-0.4 Na-140
K-3.6 Cl-105 HCO3-28 AnGap-11
[**2106-6-5**] 04:56AM BLOOD Glucose-76 UreaN-16 Creat-0.3* Na-140
K-3.7 Cl-104 HCO3-29 AnGap-11
[**2106-6-6**] 03:31AM BLOOD Glucose-92 UreaN-14 Creat-0.4 Na-141
K-4.1 Cl-105 HCO3-30 AnGap-10
[**2106-6-7**] 04:15AM BLOOD Glucose-115* UreaN-13 Creat-0.4 Na-140
K-3.8 Cl-105 HCO3-31 AnGap-8
[**2106-6-3**] 03:03AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.6
[**2106-6-4**] 02:51AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0
[**2106-6-5**] 04:56AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
[**2106-6-6**] 03:31AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.7
[**2106-6-7**] 04:15AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.7
.
Vanc levels
[**2106-6-4**] 04:21PM BLOOD Vanco-17.9
[**2106-6-6**] 03:31AM BLOOD Vanco-15.9
.
ABG
[**2106-6-1**] 05:59PM BLOOD Type-ART Rates-/12 Tidal V-400 PEEP-5
FiO2-100 pO2-410* pCO2-50* pH-7.45 calTCO2-36* Base XS-9
AADO2-268 REQ O2-51 -ASSIST/CON Intubat-INTUBATED
[**2106-6-2**] 08:03AM BLOOD Type-ART pO2-104 pCO2-38 pH-7.55*
calTCO2-34* Base XS-10
[**2106-6-2**] 02:06PM BLOOD Type-ART pO2-29* pCO2-49* pH-7.44
calTCO2-34* Base XS-6
[**2106-6-3**] 09:22AM BLOOD Type-ART Rates-/33 Tidal V-285 FiO2-40
pO2-135* pCO2-43 pH-7.50* calTCO2-35* Base XS-9
Intubat-INTUBATED.
.
Micro:
Urine Cx: 100>000 E.coli
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
.
Blood Cx: 4/21/009
Bottle 1: 2/2 Bottles with E.coli
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 8 R
.
Bottle 2: 2/2 bottles
_________________________________________________________
ENTEROCOCCUS FAECALIS
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 8 R
VANCOMYCIN------------ <=1 S
.
Surveillance blood cultures negative
.
Sputum [**2106-6-5**]: >25 PMN, sparse GNR
.
CXR [**6-1**]:
Patient is extremely kyphotic and patient's chin obscures left
hemithorax which limits evaluation of this film. An endotracheal
tube is
identified terminating above the carina. The right lung is
clear. A
persistent opacity in the left lung base is identified and
incompletely
evaluated. A PEG tube is noted in the left upper quadrant. The
osseous
structures are grossly unchanged.
.
CXR [**6-4**]:
Mandible and head obscure the course of the endotracheal tube
which could end in the left main bronchus. Left lower lobe is
still collapsed. Heart size top normal. Right lung grossly
clear.
Brief Hospital Course:
# Respiratory failure: On arrival to [**Hospital1 18**], the patient was
febrile, in respiratory distress, tachypnic and hypoxic. On her
prior hospitalization, her code status had been changed to
DNR/DNI by her HCP Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. However, in the ED, the
nursing home paper work indicated her to be full code; the ED
called her HCP who asked her to be intubated. The patient was
fiberoptically nasally intubated given her severe kyphosis. The
etiology of her respiratory distress was somewhat unclear. [**Name2 (NI) 227**]
her prior aspiration pneumonia's, it was first assumed that she
had a recurrent aspiration PNA. She was initially placed on
Vanc, Meropenem (given ESBL- Ecoli on admission 10 days
prior)and Levofloxacin empirically prior to culture data for ?
HAP vs aspiration PNA. However, her CXR remained unchanged - ?
opacification vs atelectasis at the left base-, she had minimal
sputum production and her lungs only had upper airway rhonchi. A
small amount of sputum did grown sparse GNR 2-3 days into
extubation - which may be colonization. Ultimately it was
thought that SIRS and bacteremia may have caused tachypnea and
respiratory distress rather than a primary lung process. She was
easily extubated on HD #4 and maintained good oxygenation on
nasal canula.
.
# Bacteremia: The patient's blood grew 4/4 bottles of
enterococcus and Ecoli within hours of admission. She was
initially placed on Vanc, Meropenem and Levofloxacin empirically
prior to culture data for ? HAP vs aspiration PNA. Her blood
cultures then grew Ecoli resistant flouroquinolones, but
sensitive to most other abx including Meropenem. The
enterococcus was pan-sensitive. And ultimately her antibiotic
regimen was weaned down to Meropenem. Meropenem was chosen as
her Urine grew MDR Ecoli sensitive to Meropenem, gent and Zosyn
as as she had had ESBL Ecoli in the past. Surveillance blood
cultures were all negative. The source of her bacteremia was
debated. Given the poly-microbial nature, it was thought that
her PICC vs decubitous ulcer/ ?possible osteomyelitis were the
most likely etiologies. Although he decub was to bone, the ulcer
itself looked well healed and not infected. Furthermore, plastic
surgery was contact[**Name (NI) **] and felt that she was not a surgical
candidate for surgical repair/flap. The ID service was consulted
who felt that she should have a 2 week course of meropenam.
Given that she cleared her blood cultures, no murmur on exam,
there was low suspicion for endocarditis.
.
# UTI: UA positive, Ucx with Ecoli sensitive only to Meropenem,
Gent and Zosyn. Her Foley was changed. She was treated with
Meropenem.
.
# There was difficulty administering medications through her
G-tube. Her G-tube was replaced by IR.
.
# CODE status: DNR/DNI after discussion with her HCP Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. The patient has been intubated several times now and it
was recommended that she have a trachostomy placed if she failed
extubation and required re-intubation. Her HCP [**Name (NI) **] [**Name (NI) **] did
not want a trach placed. In addition, the harm of CPR to this
frail kpyphotic elderly woman was explained. Ultimately, her HCP
decided against CPR, resucitation or re-intubation.
This has been an ongoing discussion with the family. Included
are past dicussions between medical team and family. At
discharge, there was discussion regarding long term goals and
whether patient would benefit from meeting with hospice care. It
was the medical teams opinion that patient would benefit from
further hospice discussions and would not be well served by
frequent repeat hospital admissions. Social work is well
aquainted with the patient and family and will follow-up as an
outpatient.
Date: [**2106-5-25**]
Signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1112**], MD on [**2106-5-25**] at 11:25 am Affiliation:
[**Hospital1 18**]
I spoke with Ms. [**Known lastname 98902**] [**Known lastname 802**]/HCP [**Name (NI) **] this morning. We have
decided to extubate the pt. She tends to have a rapid shallow
breathing pattern at her baseline. Yesterday she was on 5/0 for
2 hours, and her ABG after 2 hours was 7.51/48/118, suggesting
that she does not decompensate from this breathing pattern.
It's
likely due to her severe kyphoscoliosis and inability to take a
deep breath from a restrictive chest wall. Therefore, despite
an
elevated RSBI, I think it's appropriate to extubate her at this
time.
I spoke with [**Doctor First Name **] about what we will do if she fails
extubation.
I explained that if she fails and has recurrent respiratory
failure, she will require a tracheostomy (given her intubation
for >2 weeks). [**Doctor First Name **] and her brother feel that the pt would not
want a trach. Therefore, if she fails extubation, we will keep
her comfortable but will not reintubate her, knowing that she
will likely die from this. [**Doctor First Name **] and her brother are in
agreement with this plan.
Date: [**2106-6-4**]
Signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98909**], MD on [**2106-6-4**] at 5:56 pm Affiliation:
[**Hospital1 18**]
NEEDS COSIGN
Called neice Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**] regarding her aunt [**Name (NI) 4134**]. I
updated her on the blood infection, PICC line and replacement of
her G tube. I also addressed her intubation and that she meets
criteria for extubation. However, her underlying scoliosis and
poor respiratory reserve makes the chance of failure very high.
Given that this would be the third time she would be intubated
if
she failed we would recommend a tracheostomy. Dr. [**Last Name (STitle) 1445**] spoke
with her brother and they are both in agreement that she would
not want a tracheostomy. In addition, it was decided that they
would not want her to undergo CPR in the event of a cardiac
arrest.
We will perform a repeat SBT in the am and if she passes will
proceed with extubation with the understanding that if she fails
she will be transitioned to comfort focused care.
We will call Dr. [**Last Name (STitle) 1445**] prior to extubation if she passes her
SBT
tomorrow.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Medications on Admission:
- amiodarone 200 qd
- mvi
- namenda 10 q am
- namenda 5 qhs
- free h20 200cc q 6 h via G
- prevacid 30 qd via G
- senna 1 tab qhs
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (NamePattern1) **]: One (1)
Injection TID (3 times a day).
2. Amiodarone 200 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 500 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Senna 8.6 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (NamePattern1) **]: One (1) PO BID (2
times a day) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Memantine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
9. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
10. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 5 days: Day 1: [**2106-6-1**].
11. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
bacteremia
sepsis
respiratory failure s/p intubation
Secondary:
sacral decub, stage IV, chronic
Discharge Condition:
stable, sating well on nasal cannula, afebrile
Discharge Instructions:
Patient had polymicrobial bacteremia treated with meropenam for
goal 2 week course. First dose meropenam started on [**6-1**].
Patient had IR guided G-tube and PICC line replaced.
After discussion with HCP, patient is DNR/DNI
Followup Instructions:
Please follow-up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 76366**].
ICD9 Codes: 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4795
} | Medical Text: Admission Date: [**2119-1-23**] Discharge Date: [**2119-2-11**]
Date of Birth: [**2067-8-9**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
transfer from outside hospital with lung mass/lymphadenopathy
Major Surgical or Invasive Procedure:
VATS
Chest tube s/p VATS
History of Present Illness:
50 yoM w/ h/o chronic pain syndrome, history of testicular
cancer, and recent PNA presented to [**Hospital1 18**] [**Location (un) 620**] [**2119-1-20**] with
chough X 2 days productive of yellow mucus and subjective fever
without chills. (+) occasional pleuritic left flank pain. In the
ED, CXR with consolidation vs mass at RLL. He was thought to
have right lower lobe PNA and ?RAD exacerbation. He was treated
with antibiotics (Ceftriaxone), nebulizers, and admitted to
medical service for further evaluation. Given concern for mass
on initial CXR, he had a Chest CT [**2119-1-20**] that showed extensive
lymphadenopathy. w/ lymphadenopathy of left axilla, mediastinum,
and right hilum and celiac axis (worrisome for lymphoma). Course
c/b fever to 101.4, leukocytosis with bandemia. Given concern
for aspiration and history of MRSA, his antibiotic coverage was
changed to Flagyl, Ceftazidime, Azithromycin, and vancomycin. On
hospital day four, due to the patient's worsening shortness of
breath, there was concern for superimpsosed congestive heart
failure, and the patient received 40 mg IV lasix and nitropaste.
However a CXR was without CHF findings and a BNP was normal at
73. A pulmonary consult was obtained , who recommended lung
biopsy/lymph node biopsy via VATS, and the patient was
transferred to [**Hospital1 18**] for further management
Currently, the patient reports mild shortness of breath, only
with coughing. (+) diffuse chest pain only with coughing. (+)
intermittent subjective fevers/chills. (+) sputum yellow/green
with occasional streaks of blood. (+) wheezing
ROS: Mild intermittent frontal headache. No rhinorrhea, sore
throat, ear pain, stiff neck, nausea, vomiting, abdominal pain,
dysuria, or diarrhea. (+) history of IVDU (quit [**2094**]). Last HIV
test 1 yr ago (per pt at [**Hospital1 112**]) negative. No history of TB,
although pt has been incarcerated in the past. No recent travel.
(+) daughter with pneumonia.
Past Medical History:
1) s/p MVA with spleen rupture, bilateral open tibial fractures,
and head trauma
2) Chronic pain syndrome
3) Recurrent lower extremity ulcers
4) sinus tachycardia of unclear etiology
-- reflex sympathetic dystrophy PNA [**11-7**]
5) LLL PNA [**11-7**]
6) Remote history of testicular cancer: dx [**2092**] with recurrence
in [**2101**]
-- received treatment at JP [**Hospital **] hospital; reports he had an
orchiectomy in [**2092**] followed by radiation and lymph node
dissection in [**2101**].
7) GERD
8) h/o MRSA
Social History:
1 ppd X 30 yrs. (+) history of IVDU, quit in [**2094**]. No ethanol
use. Lives with his wife. Currently unemployed
Family History:
Grandfather s/p MI in 70s. Grandmother died in her sleep of
unknown cause in her 70s. No family history of cancer.
Physical Exam:
PE: Tc 100, HR 118, bpc 132/82, resp 22, 95% 50% FM
Gen: chronically ill-appearing middle-aged male, A&OX3,
intermittently coughing, no acute respiratory distress
HEENT: pupils 1.5 mm and nonreactive, EOMI, anicteric, normal
conjunctiva, OMMM slightly dry, OP clear, neck supple, shotty
cervical LAD, no JVD
Cardiac: tachycardic, regular, no M/R/G appreciated
Pulm: Diffuse course ronchi with wheezes.
Abd: NABS, soft, NT/ND, no masses, no hepatomegaly
Ext: chronic LE-scarring with superficial eschar left mid-tibia.
No discharge, erythema or edema, warm with 1+ DP bilaterally.
(+) shiny skin.
Neuro: CN II-XII grossly intact and symmetric bilaterally, [**6-8**]
upper extremities bilaterally, 4/5 strength lower extremities
bilaterally. Contracture of right ankle. Decreased sensation to
light touch of lower extremities to ankle bilaterally.
Pertinent Results:
OSH
[**2119-1-23**]
wbc 21.1 (from 19.2), HCT 42.1, MCV 75.8, RDW 18.2, Plt 577
-- PMN 78, bands 7, lymph 7, mono 7, eos 1
Na 136, K 4.0, Cl 96, HCO3 29, BUN 5, Cr 0.9, AG 11
BNP 73.7
ABG 10L FM 7.5/41/47 87%
Micro: bcx [**1-21**] pending, [**1-20**] pending,
spcx [**1-20**] >25 PMN, rare GPC cocci in pair; spcx rare growth
normal flora
[**1-23**] HIV Ab pending
[**1-20**] Chest CT w/ contrast: left axillary, mediastinal, right
hilar, retrocrural and celiac LAD (worrisome for lymphoma or
testicular metastases). Calcified subcarinal lymph nodes may be
sequelae of previously treated lymph nodes or granulomatous
exposure. Nonspecific consolidation and ground-glass opacities
in right apex and bowth lower lobes, likely of infectious
etiology. Surgical clips in RML.
[**1-21**] Abd/ pelvis CT with contrast: celiac and portal
lymphadenopathy, bibasilar nonspecific ground glass and
consolidative opacities most likely infectious in etiology, no
retroperitoneal lymphadenopathy
[**2119-1-23**] EKG: ST @ 120, nl intervals, TWF II, II, avF
Brief Hospital Course:
1) Pulmonary: Given the patient's leukocytosis/bandemia, fever,
hypoxia, the differential diagnosis includes CAP (typicals and
atypicals), PCP (multiple HIV risk factors), aspiration
pneumonia (given history of narcotic overuse), malignancy
(lymphoma, testicular CA, other), or TB. The patient was broadly
covered with ceftriaxone, azithromycin, flagyl, and vancomycin.
A CT was obtained [**2119-1-24**] that showed diffuse centrilobular
opacities and apical ground glass attenuation with bilateral
axillary and mediastinal lymphadenopathy. The patient's
eosinophils rose to 13%, raising concern for hypersensitivity
pneumonitis, eosinophilic pneumonia, or bronchopulmonary
aspergillosis. Legionella urinary antigen and HIV Ab tests were
negative. LDH was elevated, which could be suggestive of PCP or
lymphoma. PCP smear was negative X1 and sputum cultures grew
only oropharyngeal flora. Pulmonary and thoracic surgery were
consulted, and the patient underwent VATS on [**2119-1-26**] with
biopsies of left upper and lower lung and left axillary lymph
node. A PPD was placed, and was negative. ANCA and RF were
negative.
The patient developed worsening hypoxia and shortness of breath
and required a MICU stay, though no intubation. He was started
on IV steroids for his lymphadenopathy and worsening pneumonia.
He was also continued on his Vanco, CTX, and Azithromycin. He
had a CT scan to look for a PE and this found large b/lateral
pulmonary emboli. A heparin gtt was started. In this CT scan, it
was also noted that his infiltrates and lymphadenopathy
improved, so steroids, abx were also continued. The patient
improved his oxygen saturations and breathing and was
transferred back to the floor. His chest tube had been removed
without complication, including no pneumothorax, while he was in
the MICU and 2 nylon sutures were removed from the site on
[**1-31**].
After coming back to the floor, the patient did well and was on
room air at discharge. His cultures from a BAL were all negative
and after discussion with pulmonary team antibiotics were
discontinued after 9 days of vanc, ctx, azithro. He was afebrile
and his wbc was elevated (thought to be related to high dose
steroids). Diff was normal.--tapering CCST
His VATS pathology came back and demonstrated 2 discrete
morphologies affecting upper and lower lobes. In the upper
lobes, the process appeared to be infiltrative dz of the
alveoli, while lower lungs demonstrated bronchiocentric
inflammation. Path was read as acute organizing PNA with
neutrophilic predominence, likley viral/bacterial etiology. Pt's
steroids were tapered down to 20 mg QD, which he will cont for 3
days, then will switch to 10mg QD for 5 days and then off. He
will follow-up in pulmonary clinic on [**3-6**].
2) Chest wall hematoma- Pt c/o pain over LN bx site with tender
mass and expansion over a 24hr period. U/S showed hematoma. His
anticoagulation proceeded cautiously with heparin (goal PTT
50-70). His HCT remained stable and there was no significant
expansion of the lesion, so he was bridged to coumadin (goal INR
[**3-9**]). Thoracics recommended supportive and preventive
interventions including elevation of the arm, ROM training,
radial pulses, warm compresses, but felt there was no need to
evacuate the hematoma. ...Pt may need IVC filter if conts to
expand while on anticoags pt c/o of pain over the bx site. Pain
was well controlled with IV dilaudid.
2) Chronic pain syndrome/LE neuropathy/LE ulcers: The patient
was maintained on MS contin, hydromorphone, Neurontin, Flexeril.
His ulcers appeared noninfected and superficial while the
patient was in the hospital. These are chronic.
3) GI: The patient was continued on protonix throughout his
hospital course for GERD. HepBSag and Sab were negative, HCV and
HepB&C Ab were pending on discharge. Patient's LFTs were normal.
4) Hypothyroidism: Although the patient has no previous
diagnosis of hyporthyroidism, TSH 11 and free T4 0.7.
Levothyroxine 50 mcg PO daily was initiated. The patient will
require follow-up TSH within 6 weeks following discharge.
5) Diabetes: The patient's fingersticks were very elevated after
starting on IV steroids. He was started on insulin and then
required some long acting for severe hyperglycemia. The patient
had a Hgb A1C of 7.1. His glucose should come down as his
steroids are tapered but he will have to be followed closely. He
was maintained on RISS with QID fingersticks while in-house, but
#######
6) PEs: Patient had bilateral PEs as discussed above. He was
started on heparin gtt and bridged to coumadin once his chest
wall hematoma was stable. Bilateral LENIs were negative for DVT
and echo showed #####
7) Dispo: Pt will be going home with services, rather than to
rehab,as he has used up all of his [**Hospital 103876**] rehab days.
Prior to dispo, pt's PCP was updated on [**Hospital **] hospital course and
need for close follow-up care.
Medications on Admission:
Meds on transfer:
combivent nebs q4hr
neurontin 800mg TID
protonix 40 PO QD
Trileptal 150 PO TID
Colace 100mg PO BID
[**Doctor Last Name 18928**] 130mg PO qAM/qPM
vanco 1mg IV BID
flagyl 500mg OP TID
ceftazidine 2g TID
azithromycin 500mg PO QD
tylenol PRN
oxycodone 10mg PO q4hr
ronbitussin PRN
hydroxyzine PRN
flexeril PRN
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: [**2-5**] puff Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 INH* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed.
Disp:*90 Tablet(s)* Refills:*0*
7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Should be adjusted for INR [**3-9**].
Disp:*30 Tablet(s)* Refills:*2*
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
Disp:*90 Capsule(s)* Refills:*0*
11. Insulin
Glargine 10 units HS
ISS:
FS
120-180 0 units
200-250 2 units
251-300 4 units
301-350 6 units
351-400 8 units
This should be adjusted as patient's steroids are tapered.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
Disp:*1 INH* Refills:*0*
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. Hydromorphone HCl 4 mg Tablet Sig: 4-8 Tablets PO every four
(4) hours as needed for pain: Can decrease as tolerated.
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 days.
Disp:*34 Tablet(s)* Refills:*0*
17. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 16 days: Please start on [**2119-2-19**] and continue through
[**2119-3-6**].
Disp:*48 Tablet(s)* Refills:*0*
18. glucometer
Please instruct pt on usage
19. glucometer test strips
Please instruct on usage.
20. Glucose 4 g Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO PRN hypoglycemia as needed for hypoglycemia: Please take 2
tabs [**Name8 (MD) 138**] MD, and recheck blood glucose. .
Disp:*50 Tablet, Chewable(s)* Refills:*0*
21. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
injection
injection Subcutaneous Q12H (every 12 hours) for 7 days.
Disp:*14 injectioninjection* Refills:*0*
22. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
Disp:*1 inhaler* Refills:*0*
23. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
24. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
25. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
26. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
27. Oxycodone HCl 15 mg Tablet Sig: One (1) Tablet PO every four
(4) hours for 7 days.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pulmonary infection of unknown etiology
steroid-induced DM
Bilateral PEs
Axillary hematoma
chronic pain syndrome
remote h/o testicular CA
sinus tachycardia with unclear etiology
Discharge Condition:
Fair
Discharge Instructions:
Continue to take all medications as directed.
Please call your doctor and come to the hospital you experience
worsening chest pain, shortness of breath, fever/chills, or any
other concerning symptoms you may have.
Please note that your prednisone is being tapered. Please check
your fingerstick daily and keep a record of these values for
Dr.[**Last Name (STitle) 103877**], as you may need an oral hypoglycemic medication.
Followup Instructions:
1) Primary care: Please follow-up with your primary care
physician [**Name Initial (PRE) 176**] 1 week following discharge. Please call for
appointment. Hep B & C serologies should be followed up on and
TSH should be checked in approximately 5 weeks.
2) Pulmonary follow-up (very important):
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**First Name (STitle) **] Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-3-6**] 1:30
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2119-3-6**] 1:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-3-6**]
1:15
ICD9 Codes: 486, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4796
} | Medical Text: Admission Date: [**2175-5-4**] Discharge Date: [**2175-5-9**]
Date of Birth: [**2114-11-30**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male who had non-Q-wave myocardial infarction on [**2174-8-7**] treated with PTCA stent to MLAD, DLAD, and PRCA and
MRCA. The patient underwent a follow-up study in [**2175-1-7**] which showed apical and septal ischemia.
Cardiac catheterization showed ISR treated by PTCA/brachy
therapy of mid and distal left anterior descending stents,
PRCA stent and PTCA stent to PRCA.
The patient presented with recurrent exertional chest
tightness for the past three weeks.
PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
Anxiety disorder. Coronary artery disease. Status post
multiple PTCA and stent placement.
MEDICATIONS ON ADMISSION: Altace 10 mg p.o. q.d., Lopressor
12.5 p.o. b.i.d., Klonopin 1 q.d., Lipitor 20 q.d.,
.................., Aspirin, fish oil, Prozac 40 mg p.o.
q.d., Trazodone 1 tab p.o. q.h.s., Plavix 75 mg p.o. q.d.,
Imdur 30 mg p.o. q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: General: The patient was a
well-developed, well-nourished male in no apparent distress.
HEENT: Cranial nerves II-XII intact. No evidence of scleral
icterus. Moist mucous membranes. No evidence of oral
ulcers. Chest: Clear to auscultation bilaterally. Sternal
incision site with no evidence of erythema, with good
healing. Cardiovascular: Regular, rate and rhythm. No1
murmurs. Abdomen: Soft, nontender, nondistended. No
evidence of guarding or rebound.
LABORATORY DATA: CBC on [**2175-5-8**], was with a white count
of 7.2, hematocrit 27, platelet count 257.
HOSPITAL COURSE: The patient is a 59-year-old male status
post non-Q-wave myocardial infarction in [**2174-8-7**] with
history of multiple PTCA and stents presenting with
recurrence of exertional chest tightness times three weeks.
The patient underwent an uncomplicated coronary artery bypass
grafting times four (LIMA to left anterior descending,
saphenous vein graft to distal right coronary artery,
saphenous vein graft to posterolateral OM, sequential).
Postoperatively the patient was taken to the CSRU for close
observation. After being extubated, the patient maintained
good oxygenation on 2 L nasal cannula which was ultimately
weaned off.
By postoperative day #3, chest tube, Foley and pacing wires
were all removed. At this time, the patient was transferred
to the floor at which point the patient was tolerating a
regular diet, making good urine output, and maintaining good
pressure with good oxygen saturation.
Because the patient achieved level 5 Physical Therapy goal
which involves being able to climb stairs, the decision was
made to discharge the patient on postoperative day #5 in good
condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
grafting times four.
DISCHARGE MEDICATIONS: Prozac 40 mg p.o. q.d., Trazodone 25
mg p.o. q.h.s. p.r.n. insomnia, Clopidogrel 75 mg p.o. q.d.,
Oxazepam 15-30 mg p.o. q.h.s. p.r.n. insomnia, Milk of
Magnesia 30 cc p.o. q.h.s. p.r.n. constipation, Percocet [**12-8**]
tab p.o. q.4 hours p.r.n. pain, Aspirin 325 mg p.o. q.d.,
Ranitidine 150 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
Furosemide 40 mg p.o. b.i.d., Potassium 20 mEq p.o. b.i.d.,
Metoprolol 25 mg p.o. b.i.d.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) 1537**] in [**9-19**] days. The patient was also instructed to
follow-up with Dr. [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **] in [**9-19**] days.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name6 (MD) 36940**]
MEDQUIST36
D: [**2175-5-8**] 11:05
T: [**2175-5-8**] 11:07
JOB#: [**Job Number 36941**]
ICD9 Codes: 4111, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4797
} | Medical Text: Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-21**]
Date of Birth: [**2147-10-24**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Mechanical Ventillation
Lumbar Puncture
History of Present Illness:
Limited history as patient intubated and sedated. History
obtained from medical records and ED course. 43 yo F presented
to [**Hospital3 **] with complaint of CP and agitation. Woke up
[**4-18**] shaking, complaining of pressure on her chest. Concerned
for anxiety attack at home and took her to OSH. Apparently
patient usually takes cymbalata. Ran out of cymbalta 48 hours
prior to presentation. Found to be restless, short of breath,
with chest pain, delerious with hallucinations. She also
developed strange movements, concern for dystonic reaction. She
was given Ativan 1mg, Toradol 30mg, Cymbalta 60mg, Ativan 1mg,
Valium 10mg, thorazine, benadryl, and haldol at OSH. Then
propofol and versed gtt and was intubated. She was transferred
for concern for ?medication reaction vs. overdose. Head CT from
OSH was negative.
.
History of multiple suicide attempts -most recently 2 years ago
Overdosed on sleeping pills. Has had inpatient psych admissions.
Severe depression. Intermittent extreme agitation. This
situation has occurred before, in the setting of drug use.
Daughter is concerned that she may be taking opiates. She has
been physically restrained before.
.
In the ED, initial vs were: T 98.4 P 71 BP 132/87 R 18 O2 sat
100% -intubated, unknown FiO2. A+Ox 0. Pupils 2-3mm. Intubated
and sedated. Gaze downward bilaterally. No clonus or
hyperreflexia. Guaiac negative. No petichiae. Neck supple. LP
was performed. Given Ceftriaxone 2g IV x1, Acyclovir 700mg IV
x1, Vancomycin 1g IV x1. Consulted Toxicology, but they were not
reached.
.
On the floor,
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
h/o multiple suicide attempts -most recently 2 years ago OD'd on
sleeping pills. Has had inpatient psych admissions. Severe
depression. Intermittent extreme agitation. This situation has
occurred before, in the setting of drug use. Daughter is
concerned that she may be taking opiates. She has been
physically restrained before.
Cholecystectomy
Ulcerative colitis
s/p ileostomy takedown
anal stenosis s/p dilatation [**4-/2186**]
Social History:
Works as a teacher at Southeastern. No alcohol use. Occasional
Tobacco.
Family History:
Non-Contributory
Physical Exam:
Vitals: T: 96.6 BP:113/75 P: 70 R: 15 O2: 100% on FiO2 50%. Vt
450mL. PEEP 5.
General: Intubated and sedated
HEENT: Sclera anicteric, downward gaze bilaterally, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2191-4-19**] 11:16AM CK(CPK)-302*
[**2191-4-19**] 11:16AM CK-MB-6 cTropnT-<0.01
[**2191-4-19**] 04:56AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2191-4-19**] 04:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-4-19**] 03:19AM URINE HOURS-RANDOM
[**2191-4-19**] 03:19AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2191-4-19**] 02:41AM GLUCOSE-190* UREA N-6 CREAT-0.6 SODIUM-141
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14
[**2191-4-19**] 02:41AM ALT(SGPT)-11 AST(SGOT)-18 LD(LDH)-211 ALK
PHOS-73 AMYLASE-49 TOT BILI-0.3
[**2191-4-19**] 02:41AM LIPASE-16
[**2191-4-19**] 02:41AM ALBUMIN-3.4 CALCIUM-7.7* PHOSPHATE-1.8*
MAGNESIUM-2.0
[**2191-4-19**] 02:41AM VIT B12-942* FOLATE-GREATER TH
[**2191-4-19**] 02:41AM TSH-0.68
[**2191-4-19**] 02:41AM WBC-17.9* RBC-3.90* HGB-10.9* HCT-33.2*
MCV-85 MCH-27.8 MCHC-32.7 RDW-14.7
[**2191-4-19**] 02:41AM PLT COUNT-447*
[**2191-4-18**] 11:45PM estGFR-Using this
[**2191-4-19**] 02:41AM PT-14.2* PTT-29.2 INR(PT)-1.2*
[**2191-4-18**] 11:55PM LACTATE-1.0
[**2191-4-18**] 11:45PM GLUCOSE-111* UREA N-6 CREAT-0.6 SODIUM-144
POTASSIUM-3.1* CHLORIDE-115* TOTAL CO2-20* ANION GAP-12
[**2191-4-18**] 11:45PM estGFR-Using this
[**2191-4-18**] 11:45PM CK(CPK)-312*
[**2191-4-18**] 11:45PM CK-MB-8 cTropnT-<0.01
[**2191-4-18**] 11:45PM VIT B12-893 FOLATE-GREATER TH
[**2191-4-18**] 11:45PM TSH-0.72
[**2191-4-18**] 11:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2191-4-18**] 11:45PM WBC-14.7* RBC-3.91* HGB-10.7* HCT-31.6*
MCV-81* MCH-27.4 MCHC-33.9 RDW-14.3
[**2191-4-18**] 11:45PM NEUTS-76.7* LYMPHS-19.6 MONOS-2.9 EOS-0.4
BASOS-0.3
[**2191-4-18**] 11:45PM PLT COUNT-471*
[**2191-4-18**] 11:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-77
[**2191-4-18**] 11:35PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-3* POLYS-5
LYMPHS-85 MONOS-10
[**2191-4-18**] 11:29PM TYPE-ART PEEP-5 PO2-427* PCO2-32* PH-7.46*
TOTAL CO2-23 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
.
Head CT-IMPRESSION: No evidence of acute hemorrhage.
.
CT abd/pelvis:Preliminary Report !! WET READ !!
No intra-abdominal abscess.
Free fluid around the gallbladder, in the right flank and in the
pelvis.
No evidence of acute cholecystitis, although HIDA scan would be
more specific
if clinical suspicion becomes high.
.
Discharge Labs
[**2191-4-21**] 05:30AM BLOOD WBC-11.6* RBC-4.10* Hgb-11.5* Hct-34.0*
MCV-83 MCH-28.2 MCHC-33.9 RDW-14.7 Plt Ct-515*
[**2191-4-21**] 05:30AM BLOOD Plt Ct-515*
[**2191-4-21**] 05:30AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-140 K-3.7
Cl-107 HCO3-24 AnGap-13
Brief Hospital Course:
Assessment and Plan: This is a 43 yo F with a history of a
suicide attempt who presented to OSH with chest pain, SOB, and
with altered mental status.
.
# Altered Mental Status: The pt presented intubated from an OSH.
Initial differentiel included withdrawal from Cymbalta vs
reemergence of underlying psychosis. It was thought that a
toxidrom from cymbalta was less likely. Given concern for
infectious etiologies including HSV encephalitis, meningitis the
pt underwent an LP which was found to be negataive, as the pt
was briefly placed on empiric abx and acyclovir. Head CT
negative for acute intracranial process. Electrolytes did not
support metabolic abnormality. The pt was subsequently extubated
and was calm and AOX3, only complaining of chronic back pain.
Following consultations with both psych and toxicology, the
patients most likely etiology for change in MS [**First Name (Titles) **] [**Last Name (Titles) **]
from cymbalta, followed by complications [**1-24**] to polypharmcy at
the OSH in the setting of a potential panic attack. Infectious
etiologies for change in MS less likely consider exam, cultures
and imaging non-focal. Pt did have leukocytosis and fever in the
last 24hrs of her ICU course, but these resolved prior to
arrival to the floor. The pt was restarted on Cymbalta 30mg
Daily and instructed to increase to her home dose of 60mg the
following day once at home. The pt was given a 1 week supply of
Percocet to bridge her to her next pain clinic appointment.
Medications on Admission:
(Of note per patient, Could not confirm with PCP or [**Name9 (PRE) 1194**] Doc)
Cymbalta 60mg po qd
"Oxycodone 20mg TID:PRN"
Tylenol
Discharge Medications:
1. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: Two (2) Tablet
PO twice a day for 5 days: Please do not drive or operate heavy
machinery while taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
Disp:*7 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Acute Respirtory Failure
Discharge Condition:
Good. Patient ambulating. At her physical and mental baseline.
Pain controlled.
Discharge Instructions:
You were admitted from an outside hospital intubated following a
change in your mental status. This was likely secondary to a
combination of medications. You were seen by both our toxicology
and psychiatry departments that made no further recommendations
to your medication regimen.
.
Please continue to take all of your medications as listed below.
We have made no changes to your regimen.
.
Please keep all of your appointments and follow-up with your PCP
within the next 1-2 weeks.
.
Please return to hospital if you experience chest pain,
shortness of breath, fainting, loss of consciousness, fevers or
chills.
Followup Instructions:
Please follow-up with your PCP and [**Name9 (PRE) 1194**] Management Physicians
within 1-2 weeks of discharge.
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4798
} | Medical Text: Admission Date: [**2171-12-17**] Discharge Date: [**2171-12-25**]
Date of Birth: [**2094-5-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
1. Anterior diskectomy C6-C7.
2. Fusion C6-C7.
3. Anterior instrumentation C6-C7.
4. Structural allograft.
History of Present Illness:
Mr. [**Known lastname **] is a 77 year old man with history of fall at home the
night before admission. He noted that he was stepping backwards
to get into bed when he fell around 7pm; he does not remember
how it happened but did not lose consciousness. He had been
drinking alcohol prior to fall. He fell backwards and hit the
back of his head against the windowsill and then hit his
buttocks on the ground. He believed he may have landed
afterwards on his left shoulder. He got back into bed and tried
to go to sleep. Around 2-3AM, he was in so much pain from his
left shoulder that he called out to his son in the next room to
call the nurse on call from his primary care doctor's office. He
denies ever having had any neck pain. He had drank some alcohol
the evening prior to his fall.
.
He went to [**Hospital3 **] by EMS for initial evaluation and was
transferred to [**Hospital1 18**] because of the trauma and orthopedic
surgical services. Patient was noted to not have any
neurological deficits, except a left sided foot drop which he
has had at baseline.
.
Patient has a history of known spinal disc bulging in two places
in his spine, including his neck, and has had two surgeries in
the past. He notes that he has intermittent tingling in his left
hand, fourth and fifth digits, at baseline, but he feels no new
symptoms of numbness, tingling or weakness. He does have a
history of recurrent UTIs at baseline, often experiencing
symptoms of urinary urgency and frequency; he takes
nitrofurantoin daily for prophylaxis. He denies urinary
incontinence, except very occasionally, though not new since his
recent fall. He denies any urinary retention or incontinence of
stool.
Past Medical History:
-Headaches
-Cervical stenosis
- has intermittent tingling of 4th and 5th digits of left hand
-Basal Cell Carcinoma ([**2157**])
-Osteoarthritis (since [**2158**])
-COPD (since [**2158**])
-Carotid Artery Stenosis ([**2159**])
- s/p L carotid endarterectomy in [**2155**] following TIA; carotid
u/s [**7-23**] shows 50% occlusion on L and widely patent right
carotid; followed by Dr. [**Last Name (STitle) 17974**]; carotid ultrasound [**8-25**] showed
50% occlusion of right carotid; carotid u/s done [**10-27**] at NSMC
showed <50% stenosis prox r ICA and up to 50% stenosis prox left
ICA
-Hypertension, Essential
-Hypercholesterolemia
-Prostate Cancer
- s/p TURP and radiation in [**2160**]
-Coronary Artery Disease
- s/p Cath [**2167-2-23**] showed proximal 80% LAD. Right coronary
had 65% ostial right left ventric branch and 55% prox right
posterior descending artery stenosis. Circumflex was 100%
occluded in midposition w collateral filling ... Given 3vessel
CAD and L ventric dysfunction, surgical revasc recommended. Dr.
[**Last Name (STitle) **] did 4vessel CABG bypass. He had a LIMA to LAD. Had a
vein graft to posterior descending artery. Additionally had a Y
vein graft w the 1st component connecting aorta to obtuse
marginal and a wide veing graft connecting to the first
diagonal.
-s/p CABG
-Depressive Disorder
-Alcohol Dependence ([**2145**]) - quit for 28 years and started again
in [**2170**] after wife died
-Gastritis/Duodenitis
-Transient Ischemic Attack
- d/t carotid stenosis
-Actinic Keratosis
-Cardiac Arrhythmia
- an EP study [**9-23**] at [**Hospital1 112**] positive w easily inducible
monomorphic V-tach. An ICD was placed w/o complications both for
management of his inducible ventricular tachycardia and also
observed periods of bradyarrhythmia
-Lumbar Disc Disease
- lumbar MRI [**3-21**] showed [**Last Name (un) **] disc disease at multiple
levels; developed left foot drop and L5 radiculopathy. L4-L5
discectomy [**11-20**] w AFO fitting for L foot drop.
Atrial Fibrillation
-Long-term Anticoagulation
- Goal [**1-22**]
-Sleep Apnea
-Goiter - nontoxic multinodular
-Peripheral Vascular Disease
-Implantable Defibrillator
-Diverticulosis
-Syncope ([**2168**])
-Urethral stricture- post-op
-Bladder Diverticulum
-Left Foot Drop
-Recurrent UTIs
-Melanoma -
- superficial spreading RUQ abdomen [**2171-5-20**] w extension to
margin; re-excised [**7-27**] w clear margins
-Cerebrovascular Disease
-Ataxia [**1-21**] Cerebrovascular Disease
- chronic due to cerebrovascular disease ; unsteady w abrupt
changes in direction; head CT [**Hospital1 2025**] [**4-26**] showed: No acute
intracranial process. Specifically no evidence of intracranial
hemorrhage, acute territorial infarction or mass lesion. Remote
lacunar infarct involving R head of the caudate/right anterior
limb of internal capsule. Remote R superior cerebellar
infarction. Nonspecific white matter hypoattenuation likely
representing chronic microangiopathic change
Social History:
Lives at home with son. Wife died in [**2170-12-20**]. Son sleeps in
bedroom next to his. Reports prior history of significant
alcohol use; he states that he quit using alcohol for 28 years
until this year. PCP notes that he has had a couple of episodes
of drinking this fall associated with depression after wife's
death. He notes that he quit smoking 20 years ago. Used to
work for the [**Location (un) 86**] Globe as a type setter but lost his job
after everything became computerized.
Family History:
Notable for a significant history of CAD with premature death.
The patient's brother died at age 40 from an MI. A nephew died
at 38 from MI. His father died at age 60 from MI/lung disease.
Sister died at 76 from MI. Mother died at 72 from natural
causes. No other brothers or sisters. One son and one daughter;
both generally healthy.
Physical Exam:
VS: 96.9 150/90 70 20 95% on 2L
GA: AOx3, NAD
HEENT: PERRLA. slightly dry mucus membranes. dry blood in left
outer ear.
NECK: supple.
CV: Rate 70s, Regular Rhythm w occasional irreg beats. no
murmurs/gallops/rubs noted
Pulm: clear to auscultation with diffuse expiratory wheezing,
basilar crackles
Abd: soft, obese, nontender, nondistended, +BS
Back:
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: dry, old ecchymosis on forearms
Neuro: CN II-XII grossly intact; bilateral deltoids [**4-22**], Bilat
Biceps [**4-22**], Left Tricep [**3-23**], right Tricep [**4-22**]; left Hip flexor
3+/5, right Hip flexor [**4-22**]; left dorsiflexion [**3-23**], right
dorsiflexion [**4-22**]
Pertinent Results:
CT Head w/o contrast [**2171-12-17**]:
1. No acute bleed, mass, or infarct present.
2. Prominence of the superior ophthalmic veins, right greater
than left.
Recommend clinical correlation, an MRI would be useful if
further imaging
characterization is deemed necessary.
.
CT C-spine [**2171-12-17**]:
1. Anterolisthesis of the C6 vertebra with a bilateral pedicle
fractures and a jumped facet on the left. An MRI of the C-Spine
is recommended if there is concern for a ligamentous injury.
2. Severe narrowing of the spinal canal at the C3-C4 and C4-C5
level and
moderate narrowing at the C5-C6 and C6-C7 level.
.
CT Chest w/out Contrast [**2171-12-18**]:
1. Intralobular septal thickening consistent with hydrostatic
edema probably due to volume overload. Additional dependent
ground-glass opacities affecting right lung more than the left
may reflect dependent edema or secondary process such as
aspiration.
2. Small right and trace left dependent pleural effusions.
3. No evidence of thoracic spine or rib acute fracture. Please
see
separately dictated CT of the cervical spine study, which
reports bilateral pedicle fractures at the C6 vertebral body
level.
4. 3-mm diameter right apical nodule, statistically very likely
benign.
Enlarged mediastinal lymph nodes including 12 mm lower left
paratracheal and 15 mm subcarinal nodes are probably
hyperplastic or edematous. However, recommend a followup CT in
six months to document resolution of the enlarged nodes and
anticipated stability of the right apical nodule.
5. Narrowing of bronchus intermedius, probably due to
bronchomalacia related to chronic extrinsic compression by an
adjacent anterolateral osteophyte. If warranted clinically,
dynamic expiratory sequence could be added to the followup CT
(if ordered as a CT trachea study) to more fully evaluate for
bronchomalacia.
6. Low-attenuation left renal lesions are probably cysts but
incompletely
evaluated. Ultrasound examination on an outpatient basis could
be performed to confirm simple cystic characteristics if
warranted clinically.
7. Dependent gallstones within the gallbladder.
8. Mild emphysema.
.
X-ray C-spine [**2171-12-20**]: Plate and screws seen in C5, C6, C7
region.
Alignment appears satisfactory.
.
X-ray Portable Chest [**2171-12-20**]:
Median sternotomy wires and AICD is unchanged from prior.
There is unchanged cardiomegaly. Pulmonary vascular prominence
has improved since the previous study. There is no consolidation
or pleural effusions.
.
[**2171-12-17**] 06:46AM BLOOD WBC-8.7 RBC-4.37* Hgb-13.1* Hct-38.7*
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.9 Plt Ct-154
[**2171-12-21**] 04:53AM BLOOD WBC-8.5 RBC-3.79* Hgb-11.6* Hct-33.6*
MCV-89 MCH-30.6 MCHC-34.5 RDW-14.2 Plt Ct-106*
[**2171-12-17**] 06:46AM BLOOD PT-16.4* PTT-27.9 INR(PT)-1.5*
[**2171-12-21**] 04:53AM BLOOD PT-13.8* PTT-27.0 INR(PT)-1.2*
[**2171-12-17**] 06:46AM BLOOD Glucose-128* UreaN-23* Creat-0.7 Na-141
K-4.6 Cl-104 HCO3-24 AnGap-18
[**2171-12-21**] 04:53AM BLOOD Glucose-108* UreaN-15 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-28 AnGap-11
[**2171-12-20**] 04:17AM BLOOD ALT-18 AST-36 AlkPhos-43
[**2171-12-21**] 04:53AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0
[**2171-12-19**] 08:20PM BLOOD TSH-1.5
[**2171-12-17**] 06:46AM BLOOD Ethanol-15*
[**2171-12-19**] 02:01PM BLOOD Type-ART pO2-81* pCO2-46* pH-7.45
calTCO2-33* Base XS-6 Intubat-NOT INTUBA
[**2171-12-19**] 02:01PM BLOOD Glucose-93 Lactate-1.0 Na-140 K-3.5
Cl-97*
Further Imaging:
Trans Esophageal Echocardiogram:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with cavity dilation and regional
systolic dysfunction c/w CAD (PDA distribution). Moderate mitral
regurgitation. Pulmonary artery systolic hypertension
Brief Hospital Course:
Mr. [**Known lastname **] is a 77 year old male with history of COPD, chronic
systolic CHF, atrial fibrillation, s/p pacemaker/ICD, CAD s/p
CABG, depression, who presented status post fall after drinking
alcohol.
.
# C6 Fracture: Patient admitted with a fall in the context of
EtOH consumption. His
ICD was interrogated on [**12-18**] and did not show any e/o arrythmia
to have prompted the fall. He underwent fixation of his C6
vertebrae by Orthopaedics on HD3 and was then transferred to CCU
overnight for monitoring after hypotension during surgery. He
remained in a c-spine collar throughout his hospital stay. He
was pain controlled with non-narcotics (Ultram and Tylenol) as
he was felt to become delirious with opiates. He will follow up
with ortho spine.
.
# Alcohol Use: Patient quit drinking 28 years ago, after his
wife died, he became more depressed and began drinking again.
His EtOH consumption is thought to have caused his injury as his
blood EtOH level on admission was elevated. He was started on a
CIWA scale as an inpatient, but did not require any Diazepam.
.
# Atrial Fibrillation, s/p pacemaker/ICD: Patient with a h/o
atrial fibrillation with an a-paced pacemaker. He demonstrated
good ventricular conduction on presentation and was in sinus
rhythm per ECG. Prior to surgery, however, his pacemaker was
interrogated by the Electrophysiology team and the patient was
found to be in afib. A magnet was applied to his pacemaker
during surgery and his coumadin was held for the procedure.
Patient was transferred to the CCU post-op for hypotension in
the setting of Afib & intraoperative sedation. He was
transferred on a neo and esmolol drip. Overnight, the patient
was weaned off pressors and the esmolol gtt was discontinued the
following morning. His blood pressure improved to 130s
overnight. He continued to be in afib, and was rate-controlled
with IV diltiazem, followed by PO diltiazem and metoprolol. On
transfer back to the floor, his rate was in the 80's. As he was
36 hours post-procedure at that time, he was started on a
heparin gtt bridge to coumadin before transfer to the general
medicine floor. Upon transfer to the medicine floor, the
patient's heart rate increased to the 150s while in afib on 3
seperate occasions. He was titrated to 75 QID of metoprolol and
90 QID of Diltiazem. His heart rate sustained in the 80s to 90s
with this regimen. He was so stable, he will no longer need
telemetry in rehab. He was to be transitioned to long acting
forms of these medications, but patient had a dophoff placed,
and the long acting forms could not be crushed. Once his dophoff
is removed, the patient is to be switched to these long acting
medications.
.
# Left Atrial Clot: Patient with left atrial thrombus found on
TEE intra-operatively by Anesthesiology. The patient's home
warfarin & ASA were initially held prior to surgery, so it is
unclear whether this clot could be described as new or old. A
TTE was later performed which could not appreciate a clot. It is
noted that a TTE is not the best tool to visualize a left atrial
clot, as the TEE is. Unfortunately, cardiology could not find
the images of the TEE performed in the OR to assess the presence
of clot. Nevertheless, he was treated with anti-coagulation.
Approximately 36 hours post surgery, he was placed on a heparin
gtt with bridge to his Coumadin. Upon discharge his INR was not
therapeutic, but was discharged to an LTAC on a heparin gtt
until he becomes therapeutic on Warfarin. He was continued on
aspirin 81 mg.
His home medication of sotalol was discontinued, as the risk of
throwing a clot if he converted back to sinus rhythm due to this
medication was too great. This should be re-evaluated in the
outpatient setting.
.
# Chronic Systolic CHF: Patient demonstrated some evidence of
fluid overload on admission per clinical exam and CT chest, with
an O2 requirement of 2L. He was diuresed 3L prior to surgery and
was weaned from O2 successfully. A TTE was performed which
showed LVEF = 40 % and 2+ MR. After surgery, he appeared
euvolemic as well. Lisinopril was held prior to surgery, and
this was restarted prior to discharge.
.
# COPD: Patient was stable in the CCU, requiring low amounts of
O2 by NC along with Ipratropium & Albuterol nebs initially, but
was weaned successfully. He was transitioned from scheduled
atrovent, to prn, and he tolerated this well.
.
# Aspiration: Upon transfer to the floor, the patient was noted
to choke on his medications. He also had a slowly increasing
oxygen requirement. He was initially on Room air and
transitioned to 3 Liters O2. A chest x-ray was unrevealing. He
was placed on aspiration precautions and speech and swallow
evaluated him. He was found to have posterior pharyngeal
swelling secondary to intubation in surgery. He was noted to
aspirate everything he swallowed. He was placed NPO and a
dophoff was placed for medications and nutrition. He was placed
on tube feeds. He will need to be evaluated by Speed and Swallow
near the end of the week to assess whether the swelling has
improved, as this is expected. Once he passes this evaluation,
the dophoff can be removed.
.
# Depression: Patient with e/o depressed affect in the context
of alcohol abuse and per report he has become increasingly
depressed since his wife's death.
.
# Urinary Tract Infection: Patient was noted to have pyuria on
urinalysis in the CCU. He was started on Ciprofloxacin 250 mg q
12 hours, but on day 6 of 7 of his treatment, his urine culture
grew Cipro resistant E. coli. Since he was asymptomatic, cipro
was d'c'd and no new antibiotic was started. If he becomes
symptomatic, he should have a repeat UA and consider starting
another antibiotic other than Cipro.
# Code status: Patient remained FULL CODE throughout this
hospitalization.
Medications on Admission:
- lisinopril 20mg
- lyrica 225mg [**Hospital1 **]
- metoprolol 75mg [**Hospital1 **]
- tamsulosin 0.4mg daily (30min after breakfast)
- skelaxin (metaxalone) 800mg [**Hospital1 **] PRN pain
- furosemide 40mg daily
- nitrofurantoin macrocrystal 100mg QHS
- Avodart (dutasteride) 0.5mg daily
- sotalol 80mg [**Hospital1 **]
- Ipratropium-Albuterol 0.5mg-2.5mg Nebs Q3h
- Combivent 18mcg-103mcg inhaler 2puffs QID prn SOB/wheeze
- Flovent HFA 110 mcg inhale 1 puff [**Hospital1 **]
- nitroglycerin 0.4mg sublingual prn chest pain
- warfarin 2.5mg tabs-- 1.5 tabs daily
- monurol 3g oral packet PRN symptoms of dysuria (must [**Name8 (MD) 138**] MD
prior to taking)
- aspirin 81
- simvastatin 40mg
ALLERGIES: PCNs ([**12/2145**]), Fluoxetine ([**2-/2168**]), NSAIDS ([**5-/2162**])
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: Not to exceed more than 4 grams in
24 hours.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Please apply to left shoulder back 12 hours on
and 12 hours off.
10. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for sedation.
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Hold for sedation or RR < 12; to be
given for breakthrough pain.
15. 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.
16. 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.
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Heparin drip
Please titrate to PTT goal of 60-80.
20. Diltiazem HCl 60 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
21. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
QID (4 times a day).
22. Colace 100 mg Capsule Sig: [**12-21**] Capsules PO twice a day as
needed for constipation: Hold for loose stools.
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Hold for loose stools.
24. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Hold for systolic blood pressure < 100.
25. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for sbp < 100.
26. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for muscle spasms.
27. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
C6 fracture s/p C6-C7 Fusion
Atrial Fibrillation
Systolic Congestive Heart Failure
Urinary Tract Infection
Aspiration
Secondary:
Hypertension
Coronary Artery Disease
Depression
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair
Discharge Instructions:
You were admitted to the hospital because you had fallen and
broken one of the bones in your sixth cervical vertebrae. You
went to the operating room and a C6-C7 fusion was performed.
During the surgery, your heart rate became very fast and your
blood pressure became low. Strong medications needed to be given
through your veins to decrease your heart rate and increase your
blood pressure. You were taken to the Cardiac Care Unit for
close monitoring. You were successfully taken off of these
medications. You then were transferred to the regular medical
floor. Your heart rate became fast intermittently, and your
medications were adjusted to control this. Since these
medications controlled your heart rate so well, it is not
indicated for you to remain on telemetry during your rehab
course.
During your operation, an ultrasound of your heart was
performed, it demonstrated a possible clot in your left atrium.
You were started on a heparin drip with coumadin once it was
safe to do so after your surgery. You will continue to be on
this drip until your INR is at a therapeutic goal of [**1-22**].
You were also noted to be choking on your food and pills after
your surgery. Speech and swallow evaluated you and saw that you
had extensive swelling in your throat secondary to your
intubation in surgery. A feeding tube was placed and your
medications and feeding occurred through this tube. You will be
evaluated near the end of the week to see if the swelling has
decreased. Once you are able to swallow without aspirating, your
feeding tube will be removed.
You developed a urinary tract infection during your hospital
stay. You were started on Ciprofloxacin. After 6 days of taking
this medication, your urine culture grew bacteria resistant to
this antibiotic. Since your symptoms improved, this medication
was discontinued and you were not started on another antibiotic.
If you experience burning while urinating, increased frequency
or any other symptom that is concerning to you, you should be
re-evaluated for a urinary tract infection.
Your Medication changes:
You are to stop taking sotalol until you see your primary care
doctor or cardiologist re-evaluates you.
Your metoprolol was increased to 75 mg four times per day. Once
your feeding tube is removed, this medication can be changed to
a once a day long acting form. The long acting form cannot be
administered through your feeding tube.
You have a new medication called diltiazem 90 mg four times per
day. This is for your fast heart rate. Again, this can be
changed to a longer acting form once a day dosing once your
feeding tube comes
We have increased your Coumadin to 5 mg daily (from 3.75 mg
daily). This is because your INR goal was not increasing very
fast. Your doses should be adjusted by your doctor once you
leave the hospital.
For pain, you are taking Ultram 50 mg tablets as needed for
pain. Once your pain subsides in your neck and back, this
medication should be stopped.
You should contact your primary care doctor or go directly to
the emergency room if you experience sudden loss of
strength/sensation in your arms. Severe pain not relieved with
your pain medications. Chest pain, shortness of breath,
palpitations, or any other symptom that is concerning to you.
Followup Instructions:
You are to follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 25980**] upon discharge from your rehab facility.
You need to call and make this appointment.
.
You are to follow up with Orthopedic Surgery, Dr.[**Name (NI) 12040**]
office [**Numeric Identifier 25981**] [**2171-1-9**] 10am [**Hospital Ward Name 23**] 2.
.
You are to follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 25982**] [**Telephone/Fax (1) 25983**] [**2-13**] at 10:20 in [**Location (un) 1468**]
ICD9 Codes: 9971, 2930, 5990, 4019, 412, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4799
} | Medical Text: Admission Date: [**2135-5-29**] Discharge Date: [**2135-6-2**]
Date of Birth: [**2052-1-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 y/o male with PMHx of depression,ETOH abuse and insomnia who
had fall at home from standing position . He does not remember
the details of the fall.He agrees to drinking 1 bottle of 12%
alcohol nightly before dinner and had gone down at his house to
have more stiff alcohol because he could not sleep and that was
when he fell when he fell. He informs that he has had this habit
for more than 40 years and has been repeatedly told by his son
that this can harm him.
Past Medical History:
Crohn's, DVT, Pulmonary Embolus, Osteoporosis, Right femur
fracture w/ IM nail
Social History:
Married
+EtOH daily per report
Family History:
Noncontributory
Physical Exam:
Upon presentation to ED:
O: T: 98 BP: 123/73 HR:75 R:18 O2Sats 985
Gen: WD/WN, comfortable, NAD.
HEENT:hematoma right parietal Pupils: Right 2/1 L surgical
EOMs full
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: R pupil reacts to light [**2-28**] left pupil surgical.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-1**] throughout. No pronator drift
Sensation: Intact to light touch and proprioception
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
CT: CT Head OSH
small left frontal intra-axial contusion, subtle foci of
hemorrhage along right frontal cortex likely cortical contusion
Pertinent Results:
[**2135-5-29**] 10:35AM ASA-NEG ETHANOL-93* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-5-29**] 10:35AM GLUCOSE-80 UREA N-10 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
[**2135-5-29**] 10:35AM CALCIUM-8.5 PHOSPHATE-1.9* MAGNESIUM-1.8
[**2135-5-29**] 10:35AM cTropnT-<0.01
[**2135-5-29**] 10:35AM WBC-7.5 RBC-3.94* HGB-12.8* HCT-38.2* MCV-97
MCH-32.6* MCHC-33.6 RDW-14.7
[**2135-5-29**] 10:35AM PLT COUNT-228
[**2135-5-29**] 10:35AM PT-33.1* PTT-38.0* INR(PT)-3.3*
Imaging:
1. Small subarachnoid blood is identified in the bilateral
frontal lobes,
stable compared to prior study one day earlier. Small amount of
blood is also now seen in the right quadrigeminal plate
cistern, likely reflecting redistribution.
2. No intraparenchymal hemorrhage or parenchymal edema is
identified.
3. Mild parenchymal atrophy and sequelae of chronic small vessel
infarcts.
.
[**5-30**] RT thigh USS:
8 x 3.4 x 6.4 cm heterogeneous mass-like lesion in the
superficial soft
tissues over the right lateral thigh, without definite internal
vascularity.
Given the history of fall and imaging appearance, this most
likely represents a hematoma. If, however, this is a chronic
finding, present prior to trauma, other etiologies should be
considered, and could be further evaluated with MRI.
.
[**5-29**] CXR
Question possibly minimally displaced fracture involving the
lateral right eighth rib. Correlate with the apparent site of
pain which has not been
provided. Background COPD.
.
[**5-29**] CT C spine:
Extensive kyphoscoliotic curvature and degenerative changes. No
definite
acute fracture is seen, although given the extent of anatomic
distortion, if there is high suspicion for spine injury,
recommend MRI.
.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery was
consulted for the IPH which was managed non operatively. He was
transferred to the Trauma ICU for close monitoring; serial
neurologic checks and head CT scans were done and remained
stable. He was also started on Dilantin for seizure prophylaxis
and has not had any seizure activity noted during his stay. He
will continue on the Dilantin for another 4 days and then it may
be discontinued. Because he was intact neurologically and
hemodynamically stable he was transferred to the regular nursing
unit where he remained stable.
He was on Coumadin at home for history of DVT and pulmonary
embolus but this was stopped upon admission to [**Hospital1 18**] because of
his brain hemorrhage. it is being recommended by Neurosurgery
that the Coumadin can be started at his home dose 5 days after
his injury; it may be resumed on [**2135-6-3**]. His INR will need to be
checked daily until therapeutic range achieved which is [**3-2**].
His sodium level was noted to be slightly below normal; he was
fluid restricted to 1000 ml and started on salt tabs.
He was also evaluated by psychiatry at his request for inpatient
treatment for history of depression and alcohol.
He was evaluated by Geriatrics given his age, mechanism of
injury and concern for delirium noted during his ICU stay;
several recommendations pertaining to his medications were made.
His mental status is currently A & O x3.
Physical therapy worked with him daily and he has progressed to
independent with his walker.
Medications on Admission:
asacol 400', wellbutrin 150'', coumadin 5', seroquel 50'''',
fosamax q week, mvi
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**7-5**]
hours as needed for pain.
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO every Sunday.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
9. Dilantin Infatabs 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day for 4 days.
Disp:*24 Tablet, Chewable(s)* Refills:*0*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: DO NOT RESUME UNTIL [**2135-6-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
s/p Fall
Left frontal intraparenchymal hemorrhage
Right 8th rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hopsitalized after a fall where you sustained a small
bleeding injury to your brain. This injury did not require any
operations. You were started on Dilantin which is an
anit-seizure medication used to prevent seizures from happening.
You may resume your Coumadin in 2 days at the usual dose. It was
held while you were in hospital because of the bleeding in your
brain. The Neurosurgeons felt that it was safe for the Coumadin
to be restarted 5 days from your injury.
Continue with the Dilantin (anti-seizure medication) for another
4 days.
Followup Instructions:
Follow up with your PCP once you leave the hospital/inpatient
mental health facility for ongoing monitoring of your INR blood
draws and manangement of your Coumadin. You will need to call
for an appointment.
Follow up in 4 weeks with Dr. [**Last Name (STitle) **] for a repeat head CT scan.
Call [**Telephone/Fax (1) 1669**] for an appointment.
Completed by:[**2135-6-2**]
ICD9 Codes: 311 |
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